Assessing the respect of children’s rights in hospitals in Kyrgyzstan and Tajikistan

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Original: English ASSESSING THE RESPECT OF CHILDREN’S RIGHTS IN HOSPITALS IN KYRGYZSTAN AND TAJIKISTAN This report describes findings and recommendations of the assessment of children’s rights in hospital in Kyrgyzstan and Tajikistan that took place in the framework of a WHO project to support the improvement of quality of paediatric care funded by the Russian Federation. In the framework of the assessment of quality of paediatric care, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 11 hospitals in Kyrgyzstan and 10 hospitals in Tajikistan.. Assessing the respect of children’s rights in hospitals in Kyrgyzstan and Tajikistan WHO project: Improving the quality of paediatric care in the first level referral hospitals in selected countries of central Asia World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int Assessing the respect of children’s rights in hospitals in Kyrgyzstan and Tajikistan WHO project: Improving the quality of paediatric care in the first level referral hospitals in selected countries of central Asia By: Anna Isabel Fernandes Guerreiro ABSTRACT This report describes findings and recommendations of the assessment of children’s rights in hospital in Kyrgyzstan and Tajikistan that took place in the framework of a WHO project to support the improvement of quality of paediatric care funded by the Russian Federation. In the framework of the assessment of quality of paediatric care, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 11 hospitals in Kyrgyzstan and 10 hospitals in Tajikistan. Keywords CHILDREN, HOSPITALIZED PATIENTS’ RIGHTS PEDIATRICS Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest). © World Health Organization 2014 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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CONTENTS page Acknowledgement ......................................................................................................................................... 1 Executive summary ....................................................................................................................................... 1 Introduction .................................................................................................................................................. 2 Part 1: Work methodology ............................................................................................................................ 5 Part 2: Analysis of the assessment results in hospitals in Kyrgyzstan .......................................................... 8 Standard 1. Quality services for children..............................................................................................8 Standard 2: Equality and non-discrimination ..................................................................................... 13 Standard 3: Play and Learning ............................................................................................................ 14 Standard 4: Information and participation .......................................................................................... 16 Standard 5: Safety and environment ................................................................................................... 18 Standard 6: Protection ........................................................................................................................ 19 Standard 7. Pain management and palliative care .............................................................................. 20 Part 3: Analysis of the assessment results in hospitals in Tajikistan ........................................................... 22 Standard 1: Quality services for children ........................................................................................... 22 Standard 2: Equality and non-discrimination ..................................................................................... 26 Standard 3: Play and Learning ............................................................................................................ 27 Standard 4: Information and Participation .......................................................................................... 29 Standard 5: Safety and environment ................................................................................................... 31 Standard 6: Protection ........................................................................................................................ 33 Standard 7: Pain management and palliative care .............................................................................. 34 Part 4: Common recommendations for hospitals and Ministries of Health in Kyrgyzstan and Tajikistan. 35 Recommendations for the Ministries of Health: ............................................................................... 36 Recommendations for the hospitals: ................................................................................................. 36 Annexes 38 Annex 1. Kyrgyzstan – Hospital names and abbreviations ............................................................... 38 Annex 2. Tajikistan – Hospital names and abbreviations ................................................................. 38 Annex 3. Kyrgyzstan – Standard 1: Quality services for children: inputs from the self-evaluation teams ................................................................................................................................................. 38 Annex 4. Kyrgyzstan – Standard 1: Quality services for children: Children’s and parents/carers’ views and evaluation ......................................................................................................................... 40 Annex 5. Kyrgyzstan – Standard 2: Equality and non-discrimination: inputs from the self- evaluation teams ................................................................................................................................ 43 Annex 6. Kyrgyzstan – Standard 2: Equality and non-discrimination: Children’s and parents/carers’ views and evaluation ......................................................................................................................... 44 Annex 7. Kyrgyzstan – Standard 3: Play and Learning: inputs from the self-evaluation teams ....... 46 Annex 8. Kyrgyzstan – Standard 3: Play and Learning: Children’s and parents/carers’ views and evaluation .......................................................................................................................................... 48 Annex 9. Kyrgyzstan –Standard 4: Information and participation: inputs from the self-evaluation teams ................................................................................................................................................. 50 Annex 10. Kyrgyzstan – Standard 4: Information and participation: Children’s and parents/carers’ views and evaluation ......................................................................................................................... 51 Annex 11. Kyrgyzstan –Standard 5: Safety and environment: inputs from the self-evaluation teams52 Annex 12. Kyrgyzstan – Standard 5: Safety and environment: Children’s and parents/carers’ views and evaluation ................................................................................................................................... 53 Annex 13. Kyrgyzstan – Standard 6: Protection: inputs from the self-evaluation teams.................. 54 Annex 14. Kyrgyzstan –Standard 6: Protection: Children’s and parents/carers’ views and evaluation .......................................................................................................................................... 55 Annex 15. Kyrgyzstan – Standard 7: Pain management and palliative care: inputs from the self- evaluation teams ................................................................................................................................ 56 Annex 16. Kyrgyzstan – Standard 7: Pain management and palliative care: Children’s and parents/carers’ views and evaluation ................................................................................................ 57 Annex 17. Tajikistan – Standard 1: Quality Services for Children: inputs from the self-evaluation teams ................................................................................................................................................. 58 Annex 18. Tajikistan – Standard 1: Quality Services for Children: Children’s and parents/carers’ views and evaluation ......................................................................................................................... 60 Annex 19. Tajikistan – Standard 2: Equality and non-discrimination: inputs from the self- evaluation teams ................................................................................................................................ 62 Annex 20. Tajikistan – Standard 2: Equality and non-discrimination: Children’s and parents/carers’ views and evaluation ......................................................................................................................... 63 Annex 21. Tajikistan – Standard 3: Play and Learning: inputs from the self-evaluation teams ....... 65 Annex 22. Tajikistan – Standard 3: Play and Learning: Children’s and parents/carers’ views and evaluation .......................................................................................................................................... 66 Annex 23. Tajikistan – Standard 4: Information and Participation: inputs from the self-evaluation teams ................................................................................................................................................. 67 Annex 24. Tajikistan – Standard 4: Information and participation: Children’s and parents/carers’ views and evaluation ......................................................................................................................... 68 Annex 25. Tajikistan – Standard 5: Safety and environment: Inputs from the self-evaluation teams70 Annex 26. Tajikistan – Standard 5: Safety and environment: Children’s and parents/carers’ views and evaluation ................................................................................................................................... 71 Annex 27. Tajikistan – Standard 6: Protection: inputs from the self-evaluation teams .................... 73 Annex 28. Tajikistan – Standard 6: Protection: Children’s and parents/carers’ views and evaluation74 Annex 29. Standard 7: Pain management and palliative care: inputs from the self-evaluation teams75 Annex 30. Tajikistan – Standard 7: Pain management and palliative care: Children’s and parents/carers’ views and evaluation ................................................................................................ 76 page 1 Acknowledgement This report was written based on the results of the paediatric hospitals surveys in Kyrgyzstan and Tajikistan that aimed at identifying and assessing gaps between the full respect of children’s rights in hospitals and the actual practice. The assessment is part of the WHO project on improvement of quality of paediatric hospital care (QoC), funded by the Russian Federation. The original set of tools developed by the Task Force on Health Promotion for Children and Adolescents in and by Hospitals and Health Services (Task Force HPH-CA) was translated into Russian and adapted to the regional context. In overall, entire process of the assessment starting from the planning and to the report preparation was led by Vivian Barnekow and Aigul Kuttumuratova from CAH programme of WHO Regional Office for Europe. Natalia Rossin, an intern at WHO contributed to the work on editing Russian questionnaires, their dissemination and initial data analysis. The report was prepared by WHO consultant Ana Isabel Guerreiro. We would like thank WHO Country offices in Kyrgyzstan and Tajikistan, in particular Kubanychbek Monolbaev and Zulfiya Pirova, for support in organizing data collection in the hospitals. Special thanks will go to the national focal points in Kyrgyzstan Gulsun Rakova and Aigul Jailoobaeva and in Tajikistan Nargiz Nuralieva and Kholmirzo Davlatov, and the hospital assessment teams for coordinating the process of primary data collection in the project hospitals. Executive summary The assessment of children’s rights in hospital in Kyrgyzstan and Tajikistan took place in the framework of a WHO project to support the improvement of quality of paediatric care (QoC), funded by the Russian Federation. The main goal of the project is to reduce childhood mortality through strengthening national health systems capacity in improving the quality of paediatric care for common childhood illnesses in the first-level referral hospitals. In the framework of the assessment of QoC, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 11 hospitals in Kyrgyzstan and 10 hospitals in Tajikistan. The majority of parents and children, including adolescents were satisfied with the overall care received in most participating hospitals. Concerning the respect of specific rights in hospitals in Kyrgyzstan, 10 of the 11 participating hospitals have adopted a Charter on Children’s Rights in Hospital, between 2008 and 2011; there is attention in most hospitals to children’s right to privacy, palliative care and the right of children to be protected from all forms of violence; and 8 hospitals have introduced a hospital policy defining criteria on children’s right to informed consent. Some barriers were identified in the access of children to hospital health care, namely due to payment of expensive drugs for children with chronic diseases, transportation difficulties and referral to hospital. The assessment of children’s right to pain management also shows that more attention should be given to this right. Concerning the respect of specific rights in hospitals in Tajikistan, no hospital had adopted, disseminated and implemented a Charter on Children’s Rights in Hospital at the time of the assessment, however, based on the inputs of the self-evaluation teams, mainly management, a Charter on Children’s Rights in Hospital was adopted in 6 hospitals and partially adopted in another one. Inputs from both the self-evaluation teams and children and parents/carers demonstrate that there is significant attention given to children’s right to pain management; 8 hospitals have adopted policies outlying criteria on children’s informed consent; and all hospitals have adopted policies and practices to ensure that children have the right to access health care services without discrimination. Areas that need more attention in hospitals in Tajikistan include page 2 quality of care in terms of protocols and training of health professionals; and some dimensions of access to health care. Common findings in relation to the respect, protection and fulfilment of children’s rights in hospitals in both countries include: the frequent discrepancy between what parents are entitled to and hospital practice and in the difference of care from child to child; the lack of attention to children’s right to play and learning; and the need to improve the hospitals’ infrastructures. The main recommendations include enacting evidence-based national legislation and protocols on key aspects of hospital health care for children; ensure the implementation of national legislation and protocols by health care providers; and the allocation of budgets to renovate health infrastructure and supply necessary hospital equipment and drugs. A greater attention must be paid in both countries to children’s right to information and participation, to food and to play and learning. Introduction The history of tool development. In January 2009, the Task Force on Health Promotion for Children and Adolescents in & by Hospitals and Health Services (hereafter Task Force HPH- CA) published the first edition of the Self-evaluation Model and Tool on the Respect of Children’s Rights in Hospital (SEMT) (Task Force HPH-CA, 20091). The tool was prepared by Task Force HPH-CA members, which included a variety of professionals such as paediatricians and paediatric nurses, psychologists and other, based in paediatric and general hospitals, NGOs and Public Health institutions in Europe, Canada, Australia and the United States of America. The preparation of the tool was based on an exploratory carried out in 2004 in 114 paediatric hospitals and departments of 22 WHO Europe countries, which highlighted a gap in the adoption of Charters on Children‘s Rights in Hospital and, where these had been adopted, the lack of tools to monitor, evaluate and improve the respect of children‘s rights in the hospital setting. The tool was informed by the Convention on the Rights of the Child (CRC), the Charter of the European Association for Children in Hospital (EACH), the Charter of the International Children’s Palliative Care Network and the standards of the Child-Friendly Healthcare Initiative and prepared in consultation with experts at WHO Headquarters, UNICEF Office of Research, the Healthcare Commission for England, the Greek Ombudsperson and the HPH Task Force on Migrant-Friendly and Culturally-Competent Hospitals. The SEMT was made available in 10 languages, it was widely disseminated and a pilot project was conducted in a group of 17 hospitals in Europe and Australia (Simonelli and Guerreiro2, 2010). The results of this process lead to the preparation of a set of tools for the assessment and improvement of children’s rights in hospitals targeting five groups of stakeholders, namely hospital management, health professionals, children aged 6-11 and for children and adolescents aged 12-18 and a tool for parents and carers (Task Force HPH-CA, 20133). The Committee on the Rights of the Child, in its General Comment Nº 15 on the right of the child to the enjoyment of the highest attainable standard of health (Article 24 of the Convention on the Rights of the Child, hereafter right to health), interprets children’s right to health “as an 1 Task Force HPH-CA (2009). Self-evaluation Model and Tool on the Respect of Children’s Rights in Hospital; assessed on 8 May 2014: http://www.hphnet.org/images/stories/Final_Self-evaluation_Tool_EN.pdf 2 Simonelli F and Guerreiro AIF (eds); The respect of children’s rights in hospital: an initiative of the International Network on Health Promoting Hospitals and Health Services. Final Report on the implementation process of the Self-evaluation Model and Tool on the respect of children’s rights in hospital. January 2010; assessed on 8 May 2014: http://www.hphnet.org/images/stories/Task_Force_HPH-CA.Final_Report_SEMT1.pdf 3 Task Force HPH-CA (2013) Children’s rights in Hospital and Health Services: Manual and Tools for assessment and improvement; ossesse on 8 May 2014: http://www.hphnet.org/members/task-forces/20-members/tf1/1551-hp- for-children-a-adolescents-in-a-by-hospitals page 3 inclusive right, extending not only to timely and appropriate prevention, health promotion, curative, rehabilitative and palliative services, but also to a right to grow and develop their full potential and live in conditions that enable them to attain the highest standard of health through the implementation of programmes that address the underlying determinants of health.”4 Significantly, it also recognizes not only the importance of children’s right to health to the enjoyment of other rights and to children’s achievement of their full potential, but also the dependency of the right to health on the realization of other rights. Children’s rights must be realized in all of children’s life settings. Children’s stay in hospital – as any direct contact of children with the public system – can be regarded as an opportunity to enhance children’s rights, to address the underlying determinants of health and contribute to children’s overall well-being and development. Taking this into account, the aim of this report will be two-fold. Firstly, it aims to present the results on the assessment of the respect of children’s rights in 11 hospitals in Kyrgyzstan and 10 hospitals in Tajikistan. Secondly, it aims to draw recommendations and identify specific actions for improvement to both health providers and the Ministries of Health, by taking into consideration States’ responsibility and the role of health care services, in line with the respect, protection and fulfilment of children’s right to health. The assessment of children’s rights in hospital in Kyrgyzstan and Tajikistan took place in the framework of a WHO project to support the improvement of quality of paediatric care (QoC), funded by the Russian Federation. This work is also a part of the broader initiative by the WHO/Europe to strengthen children’s rights in health services. The main goal of the project is to reduce childhood mortality through strengthening national health systems capacity in improving the quality of paediatric care for common childhood illnesses in the first-level referral hospitals. In the framework of the assessment of QoC, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in hospitals. The original Manual and Tools (Task Force on Health Promotion for Children and Adolescents in and by Hospitals and Health Services, International Network of Health Promoting Hospitals and Health Services, 2012) are available in English5, but for the implementation in Kyrgyzstan and Tajikistan the set of tools was translated into Russian and adapted to the local context. Each tool was prepared for a group of stakeholders, namely a) hospital management, b) health professionals, c) children aged 6-11 and children and adolescents aged 12-18 and e) parents and carers. The tools aim to assess children’s rights in hospital, in accordance to seven standards, as follows: Standard 1 evaluates the ‘best quality possible care’ delivered to all children, understood as a care that takes into account the clinical evidence available, the respect of children’s rights and patient and family’s views and wishes. Standard 2 evaluates to what extent the health care services respect the principles of equality and non-discrimination of all children. Standard 3 evaluates how play and learning are planned and delivered to all children. Standard 4 evaluates the rights of all children to information and participation in health care decisions affecting them and the delivery of services. Standard 5 evaluates to what extent health care services are delivered in a safe, clean and appropriate environment for all children. Standard 6 evaluates the right of all children to protection from all forms of physical or mental violence, unintentional injury, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse. 4 Committee on the Rights of the Child; General Comment Nº 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (article 24); CRC/C/GC/15; I. paragraph 2. 5 The set of tools is accessible at: http://www.hphnet.org/members/task-forces/20-members/tf1/1551-hp-for- children-a-adolescents-in-a-by-hospitals page 4 Standard 7 evaluates the provision of pain management and palliative care to children. For each standard, several sub-standards and specific questions for the different groups of stakeholders were identified. The questions are adapted to each of the groups, however they aim to address and gather information on the same issues. The assessment deals with children’s rights in hospital, but it also tackles some parental rights. Indeed, parents/carers have a fundamental role in promoting the overall healthy child development through early diagnosis of diseases, educating against risky behaviour, teaching healthy eating habits, stimulating learning and enhancing children’s capabilities. For these reasons, to the extent possible, parents/carers should be seen as a partner during children’s hospitalization, their support should be sought and they should be given all information and instruments to be aware of how they can best take care of their child. This includes educating parents/carers on how to take care of a child with a specific illness (including chronic diseases and disabilities), raising awareness where parents’/carers’ behaviour is bad for their child (i.e. smoking), amongst other skills. The report will be structured in the following manner: Part 1: Work methodology used for the assessment of children’s rights in hospital in Kyrgyzstan and Tajikistan; Part 2: Analysis of the assessment results in hospitals in Kyrgyzstan. This section includes the information gathered for each of the standards on children’s rights in hospital and the identification of the main areas for improvement in hospital, with concrete examples; Part 3: Analysis of the assessment results in hospitals in Tajikistan. This section includes the information gathered for each of the standards on children’s rights in hospital and the identification of the main areas for improvement in hospital, with concrete examples; Part 4: Common recommendations for hospitals and Ministries of Health in Kyrgyzstan and Tajikistan. Where appropriate, the results of the assessment on the respect of children’s rights in hospital will be complemented with data gathered in the overall QoC study. page 5 Part 1: Work methodology Each country assigned two national experts responsible for the overall data collection. They travelled to the participating hospitals and conducted briefing of respective hospital staff or focal points on the self-assessment process: tools, methodology, and time frame. Prior to this visit each hospital assigned two staff members that carried out a self-assessment (hospital study team). The number of participants varied according to the hospital size and number of patients being hospitalized at the time of study. However, a minimum number of participants per hospital had been established, namely: 3 children aged 6-11, 3 children aged 12-18, and 2 parents/carers to be interviewed; and 1 parent/carer, 1 nurse, 1 doctor and 1 management representative to participate in the focus group. Mixed approaches were applied. All children were individually interviewed. Most of the parents/carers6 were interviewed and some also participated in small group discussions. Focus group discussions and some interviews were conducted with health workers and the management team. The interviews with patients were confidential and prior consent to participation was requested. Once the data collection process was completed, the data were forwarded to WHO Child and Adolescent Health Program (CAH) for analysis and preparation of a final report on the respect of children’s rights in the hospitals. In Kyrgyzstan, 11 hospitals participated in the assessment of the respect of children’s rights in hospital (see Annex 1 for list of participating hospitals). The average number of participants was 28 per hospital and they included hospital management, doctors and nurses from various departments, parents/carers and children, from 6 to 18 years old. The average number of meetings held per hospital was 7. In every hospital, both work group discussions and individual interviews took place to assess the respect of children’s rights. See Summary Chart 1 for detailed information per hospital. In Tajikistan, 10 hospitals participated in the assessment of the respect of children’s rights in hospital (see Annex 2 for list of participating hospitals). The average number of participants was 21 per hospital and they included hospital management, doctors and nurses from various departments, parents/carers and children, from 6 to 18 years old. The average number of meetings held per hospital was 11. In every hospital, both work group discussions and individual interviews took place to assess the respect of children’s rights. See Summary Chart 2 for detailed information per hospital. Summary Chart 1. Kyrgyzstan – General information on the self-evaluation process and work methodologies Hospital  Process Leader  Number of  participants  Type of participant  Number  of  meetings  Work  methodology   TDH  Hospital  Management,  National  Coordinator  34  Hospital  management, doctors  and nurses (pediatric,  surgery, resuscitation  departments),  parents/carers,  children  9  Joint group  discussion +  Individual  interviews  JODH  Hospital  Management,  National  Coordinator  26  Hospital  management, doctors  and nurses  (unspecified  8  Joint group  discussion +  Individual  interviews  6 Note: The group parents/carers was mostly composed of mothers, although in some cases grandparents and  other relatives participated.  page 6 departments),  parents/carers,  children  BCDH  Hospital  Management,  National  Coordinator  31  Hospital  management, doctors  and nurses  (unspecified  departments),  parents/carers,  children  8  Joint group  discussion +  Individual  interviews  IKJRH  Hospital  Management,  National  Coordinator  30  Hospital  management, doctors  and nurses (pediatric,  surgery, resuscitation  departments),  parents/carers,  children  6  Joint group  discussion +  Individual  interviews  TOH  Hospital  Management,  National  Coordinator  25  Hospital  management, doctors  and nurses (pediatric  somatic, resuscitation  departments),  parents/carers,  children  6  Joint group  discussion +  Individual  interviews  KBDH  Hospital  Management,  National  Coordinator  26  Hospital  management, doctors  and nurses (surgery,  somatic, infectious  departments),  parents/carers,  children  7  Joint group  discussion +  Individual  interviews  IADH  Hospital  Management,  National  Coordinator  30  Hospital  management, doctors  and nurses (infectious  department),  parents/carers,  children  6  Joint group  discussion +  Individual  interviews  MDH  Hospital  Management,  National  Coordinator  29  Hospital  management, doctors  and nurses (somatic  and surgery  departments),  parents/carers,  children  6  Joint group  discussion +  Individual  interviews  BADH  Hospital  Management,  National  Coordinator  24  Hospital  management, doctors  and nurses  (infectious, somatic  and therapeutic  5  Joint group  discussion +  Individual  interviews  page 7 departments),  parents/carers,  children  NCMCH  Hospital  Management,  National  Coordinator  32  Hospital  management, doctors  and nurses (paediatric  resuscitation, surgery,  endocrinology,  urological  departments),  parents/carers,  children  8  Joint group  discussion +  Individual  interviews  SDH  Hospital  Management,  National  Coordinator  25  Hospital  management, doctors  and nurses (paediatric  somatic department),  parents/carers,  children  7  Joint group  discussion +  Individual  interviews  Summary Chart 2. Tajikistan – General information on the self-evaluation process and work methodologies Hospital  Process Leader  Number of  participant s  Type of participant  Number  of  meetings  Work  methodology   KTRH  Hospital  Management,  National  Coordinator  15  Hospital management,  doctors and nurses  (paediatric, somatic and  surgery departments),  parents/carers, children 9  Joint group  discussion +  Individual  interviews  CDHJ  Hospital  Management,  National  Coordinator  28  Hospital management,  doctors and nurses  (paediatric somatic,  infectious, surgery,  departments),  parents/carers, children 13  Joint group  discussion +  Individual  interviews  CDHR  Hospital  Management,  National  Coordinator  17  Hospital management,  doctors and nurses  (paediatric, somatic,  resuscitation and  surgery department),  parents/carers, children 13  Joint group  discussion +  Individual  interviews  CDHVa  Hospital  Management,  National  Coordinator  28  Hospital management,  doctors and nurses  (paediatric somatic,  infectious, surgery,  departments),  parents/carers, children 13  Joint group  discussion +  Individual  interviews  CDHP  Hospital  Management,  14  Hospital management,  doctors and nurses  11  Joint group  discussion +  page 8 National  Coordinator  (paediatric somatic,  infectious  departments),  parents/carers, children Individual  interviews  CDHH  Hospital  Management,  National  Coordinator  14  Hospital management,  doctors and nurses  (paediatric, somatic,  infectious and surgery  departments),  parents/carers, children 11  Joint group  discussion +  Individual  interviews  CDHF  Hospital  Management,  National  Coordinator  13  Hospital management,  doctors and nurses  (paediatric, somatic,  infectious and surgery  departments),  parents/carers, children 10  Joint group  discussion +  Individual  interviews  CDHVo  Hospital  Management,  National  Coordinator  28  Hospital management,  doctors and nurses  (paediatric, somatic,  surgery and  resuscitation  departments),  parents/carers, children 13  Joint group  discussion +  Individual  interviews  CDHK  Hospital  Management,  National  Coordinator  38  Hospital management,  doctors and nurses  (paediatric, somatic,  infectious and surgery  departments),  parents/carers, children 13  Joint group  discussion +  Individual  interviews  CDHY  Hospital  Management,  National  Coordinator  19  Hospital management,  doctors and nurses  (paediatric  resuscitation, surgery,  somatic, infectious  departments),  parents/carers, children 10  Joint group  discussion +  Individual  interviews  Part 2: Analysis of the assessment results in hospitals in Kyrgyzstan Standard 1. Quality services for children All services provided for children aim at delivering the best quality possible care, by taking into account clinical evidence available, the respect of children’s rights and patient and family’s views and wishes. 1.1. The hospital ensures that all institutional activities are based on the best evidence available and that staff are adequately trained. page 9 The question presented to children and parents/carers for the consideration of this right was: “Do you believe you received the best care possible?” Most of the children and parents/carers that participated in the assessment were satisfied with the care received. Some of the children’s and parents’/carers’ inputs are presented below: IADH: “I received the best care from nurses in the hospital” (adolescent 12-18 years old); TDH, BCDH, IKJRH, KBDH, IADH, NCMCH, MDH, SDH, JODH: “People I met in the hospital were friendly, they were attentive to my opinion, I was happy with the services provided” (adolescents 12-18 years old); IADH: “My child didn’t receive the best care” (parents/carers). The self-evaluations on the respect of children’s rights in 11 Kyrgyz hospitals show that there is attention to children’s right to the health. Self-evaluation teams in all hospitals stated that care is delivered based on national and international guidelines. However, the assessment of QoC demonstrated that the adoption and implementation of guidelines must follow a stricter method. In 8 hospitals, health care providers (doctors and nurses) who work with children were trained in paediatric care. 1.2. The hospital ensures that all types of services provided within the organization are regularly monitored and evaluated. Self-evaluation teams in all hospitals stated that audits are carried out to services, to ensure that they comply with the organizational policy. Self-evaluation teams stated that in 8 hospitals regular patient satisfaction surveys are carried out. Children in 5 hospitals had participated in a patient satisfaction survey and had been told how the information gathered would be used. In 4 hospitals children had participated in a patient satisfaction survey, but were not sure whether the results had contributed to decision-making. 1.3. The hospital has a Charter on Children’s Rights in Hospital, in line with the United Nations Convention on the Rights of the Child. 10 of the 11 participating hospitals adopted a Charter on Children’s Rights in Hospital, either in 2008 (NCMCH), in 2009 (TDH, IKJRH, TOH and SDH) or 2010 (JODH, BCDH, KBDH, MDH and BADH). Every hospital that had adopted the Charter on Children’s Rights in Hospital stated that it was displayed, in between 30% and 86% of hospital wards. However, upon further analysis, through the inputs provided by the self-evaluation teams, there is evidence showing that in 5 participating hospitals, a Charter on Children’s Rights has not been adopted and it is not displayed in the walls of all wards; and in 1 hospital it has only been partially adopted and is partially displayed in wards. In JODH Hospital, the Charter on Children’s Rights has been adopted in the context of improvement of health care quality. See Summary Chart 3 for detailed information per hospital. Children’s inputs show mixed experiences concerning access to a Charter and/or related information about children’s rights in hospital. In some cases, information about children’s rights was given orally by a health professional, or children had seen a copy of the Charter or they had not seen a copy of the Charter and no one had informed them of their rights. Some of children’s inputs on the dissemination of children’s rights in hospitals are presented below: TDH: “(A) health worker talked with me about my rights” (adolescent 15 years old); BCDH, IKJRH, KBDH, IADH: “I have seen the Charter on Children’s Right and health care workers talked with me about my rights” (adolescent 16 years old, 12-18 years old, parent/carers); IADH: “I have seen the Charter on Children’s Right on the wall, but health care workers didn’t talk with me about children’s rights” (adolescent 16 years old, 12-18 years old, parent/carers). page 10 Summary Chart 3. Status of adoption and implementation of a Charter on Children’s rights in hospitals in Kyrgyzstan Hospital  Has a Charter  on Children’s  Rights been  adopted?  Is the charter  displayed?  OTHER RELEVANT INFORMATION  TDH  Yes, adopted in  2009  Yes, in 40% of  wards  However, based on inputs from the self‐ evaluation teams the hospital didn’t adopt a  Charter on Children’s Right and it was not  displayed in the walls of all wards  JODH  Yes, adopted in 2010  Yes, in  approximately  50% of wards  Adopted in the context of improvement of  health care quality  BCDH  Yes, adopted in  2010  Yes, in 35% of  wards  However, based on inputs from the self‐ evaluation teams the hospital partly adopted a  Charter on Children’s Right and it was partly  displayed in the walls of all wards  IKJRH  Yes, adopted in  2009  Yes, in 50% of  wards  Based on inputs from the self‐evaluation teams a  Charter on Children’s Right is displayed in the  walls of paediatric department  TOH  Yes, adopted in  2009  Yes, in 50% of  wards  However, based on inputs from the self‐ evaluation teams the hospital didn’t adopt a  Charter on Children’s Right and it was not  displayed in the walls of all wards  KBDH  Yes, adopted in  2010  Yes, in 30% of  wards  However, based on inputs from the self‐ evaluation teams the hospital didn’t adopt a  Charter on Children’s Right and it was not  displayed in the walls of all wards  IADH  n/a  n/a  Based on inputs from the self‐evaluation teams  the hospital adopted a Charter on Children’s  Right and it was displayed in the walls of all  wards  MDH  Yes, adopted in  2010  Yes, in 40% of  wards  However, based on inputs from the self‐ evaluation teams the hospital didn’t adopt a  Charter on Children’s Right and it was not  displayed in the walls of all wards  BADH  Yes, adopted in 2010  Yes, in 30% of  wards  Based on inputs from the self‐evaluation teams  the hospital adopted a Charter on Children’s  Right and it was displayed in the walls of all  wards  NCMCH  Yes, adopted in  2008  Yes, in 86% of  wards  Based on inputs from the self‐evaluation teams  the hospital adopted a Charter on Children’s  Right and it is displayed in the walls of all wards  SDH  Yes, adopted in  2009  Yes, in 35% of  wards  However, based on inputs from the self‐ evaluation teams the hospital didn’t adopt a  Charter on Children’s Right and it was not  displayed in the walls of all wards  page 11 1.4. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization. The self-evaluation teams reported that 10 hospitals allow parents/carers to stay with children during their hospitalization, including overnight stay and in 3 hospitals parents/carers are also allowed to stay with their child during procedures, except anaesthesia induction. However, in 1 hospital only parents/carers with children under 7 years old could stay overnight, in 1 hospital overnight stay included a fee; and in at least 5 hospitals, children and parents/carers reported that the parent was not able to stay overnight, although they wanted to. Parents’/carers’ inputs are presented below: TDH, BCDH, IKJRH, KBDH, IADH, NCMCH, SDH, JODH, JODH: “Parents/carers were always with me during my stay in the hospital, including overnight” (children 6-11 years old, adolescents 12-18 years old, parent/carer);  NCMCH: “I didn’t want my parents/carers to stay with me and they didn’t stay with me, but mother stayed with me during procedures” (adolescent 12-18 years old); IKJRH: “Parents/carers were not always with me during my stay in the hospital and didn’t stay with me overnight because I am a big boy” (7 years old); IKJRH: “Parents/carers were not with me during my stay in the hospital and didn’t stay with me overnight because I am an adult” (adolescent 11-18 years old); MDH: “Parents/carers didn’t stay with me in the hospital though I wanted them to stay with me” (adolescent 12-18 years old); TOH, NCMCH, MDH: “I was not allowed to stay with the child during his stay in the hospital, including presence during procedures, but I wanted to stay there (parents/carers); TOH, TDH, IADH, MDH: “Parents/carers were not always with me during my stay in the hospital and didn’t stay with me overnight” (6-11 years old, adolescent 15 years old); BCDH: “I was allowed to stay with the child during his stay in the hospital, including presence during procedures, but was not allowed to stay overnight there (parents/carers). Parents/carers in every participating hospital reported that they were provided with free food during their child’s stay in the hospital, notwithstanding the fact that self-evaluation teams reported that in only 6 hospitals there was this possibility. 1.5. The hospital pays special attention to the rights of adolescents to health care. In 7 hospitals there is a specific adolescent-friendly health service. In order to assess further the effective of the service, more information should be gathered. More information on the type of services to be provided is included below in point g). There are several areas that need improvement to ensure that all children have access to quality of care, namely: a) Ensure that hospital care delivered to children is based on evidence-based national and/or international guidelines: The care delivered by health professionals in hospitals should be based on evidence- based national and/or international guidelines. Where missing, the Ministry of Health should adopt clinical guidelines and protocols to guide hospitals in case-management and in essential aspects of children’s right to health, including establishing criteria for children’s informed consent; confidential services for adolescents; establishing a ‘paediatric age’; among other. The clinical guidelines and protocols will then have to be made available to all hospitals and medical staff working with children. The protocols should be applied by medical staff in daily practice and their implementation should be monitored. Where necessary, the Ministry of Health should allocate budgets for the implementation of guidelines and protocols. b) Ensure effective monitoring and evaluation systems: page 12 An adequate system for planning, monitoring and evaluation is essential to the effective functioning of a hospital and to the rational use of budgets. Services must adopt or prepare instruments to assess all aspects of service delivered to children. The tools used for this project are an example of how to assess the respect, protection and fulfilment of children’s rights in hospital. Children’s medical charts are also a useful mechanism to register and assess the care delivered to children. Where available, hospitals are encouraged to use Information Technology systems, because it makes data gathering simpler, more efficient and easy to analyse. c) Increase attention to patient satisfaction: 8 Kyrgyz hospitals are already supporting patients’ satisfaction by carrying out regular patient satisfaction surveys. All hospitals should implement further patient satisfaction surveys and ensure that the feedback received from children and parents/carers is used to improve health care services. Patient satisfaction surveys may be carried out during or at the end of children’s stay in hospital or once they have returned home. Nowadays, there are a number of user-friendly formats, enabling children of all ages and with learning disabilities to participate and express their views on the care received. d) Adoption and dissemination of a Charter on Children’s Rights in Hospital: The Charter should be adopted; made available to children through the display of the Charter in all hospital wards and/or in print form in different formats; and hospital staff should be trained to understand what each of the rights entail and how to apply them in daily practice. Complementary actions to ensure the implementation of the Charter may include assessing the respect of children’s rights in evaluation processes such as the present one. e) Enable at least 1 parent to stay with their child, including overnight stay: Firstly, it is important for hospitals to understand why self-evaluation teams are reporting that parents/carers can stay with their child overnight and parents/carers are not being allowed to enjoy that right. Secondly, hospitals should undertake actions to change that. At least 1 parent should be able to stay with their child, including overnight stay. f) Progressively enable parents/carers to stay with their child during procedures: Hospitals should progressively enable parents/carers to stay with their child during procedures, as it can be beneficial for child health outcomes, medical staff treating the child and parents/carers alike. More and more, parents/carers are being allowed and encouraged to stay with their child at all times, including during procedures. In some countries and hospitals, parents/carers are also able to accompany their child during anaesthesia induction. Hospitals are promoting parents/carers stay during procedures because it can help to reduce children’s anxiety, by providing comfort to them; parents/carers can often support medical staff in preparing children or helping in procedures; and it may help parents/carers to better understand their child’s condition and how to treat them at home, where applicable. g) Consolidation of adolescent-friendly health services: Although in 7 participating hospitals, there are already adolescent-health services in place, self-evaluation teams reported a need to establish adolescent-friendly health services and to improve those already in place, in other cases. In order to reach out to adolescents, hospitals must be aware of the community they are serving, in order to tailor page 13 the services to better meet their needs. Services should be particularly aware of adolescents’ right to privacy and counselling, with respect to advice and counselling on health matters; access to sexual and reproductive health programmes; and reaching out to groups of adolescents that may be particularly at risk, including adolescent mothers/parents and adolescents with disabilities, among others. See Annexes 3 and 4, for summary of inputs on Standard 1 by self-evaluation team and children and parents/carers, respectively. Standard 2: Equality and non-discrimination All children should be able to access health care and undergo any type of treatment without discrimination of any kind, irrespective of the child’s or his or her parents/carers’ or legal guardians’ race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. 2.1. The hospital fulfils the rights of access of all children without discrimination of any kind. In 9 hospitals, there is a hospital policy to ensure that children of minority and other status are not discriminated and have equal access to health services. The assessment of QoC found some barriers regarding access, namely payment of expensive drugs for children with chronic diseases, transportation and referral to hospital. A parent/carer in IADH hospital stated: “More comprehensive examination of children is required in kindergartens, orphanages, and “at-risk groups” of children”. 2.2. The hospital delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents/carers. In 6 hospitals, culturally competent staff is available and in 4 hospitals interpreters are provided by the hospital, upon necessity. Children in 9 hospitals said they felt treated with respect. In 3 hospitals, the language needs of adolescents were met by the provision of an interpreter (1 hospital) and the staff’s knowledge of different languages (2 hospitals). In 5 hospitals, adolescents and parents/carers stated that no interpreter had been provided and in 1 hospital a parent/carer stated “I don’t think that everyone receives the same treatment in the hospital, my child was not treated with respect”. 2.3. The hospital ensures the respect of children’s privacy at all times. Inputs from both the self-evaluation teams and children and parents/carers demonstrate that there is attention in most hospitals to children’s right to privacy. In 8 hospitals, there is the possibility for children to be examined by a doctor of the same gender; in 6 hospitals, there is a private area for performing examinations; in 5 hospitals, children are informed in a private area; and in 5 hospitals children can be hospitalised in single or double rooms, upon request. Children participating in the evaluation in 8 hospitals reported that they were given the possibility to be examined by a doctor of the same gender, children in 7 hospitals were examined and informed in private areas and in 7 hospitals adolescents were given the opportunity to stay in a double room. Some of children’s and parents/carers inputs are presented below: TDH, BCDH, IKJRH, KBDH, NCMCH, MDH, SDH, JODH: “I (child) was given an opportunity to be examined by the doctor of the same gender” (adolescent 12-18 years old, parent/carers); IKJRH, KBDH, IADH, NCMCH, MDH, SDH, JODH: “I (child) have an opportunity to stay in double room in the hospital” (adolescents 12-18 years old, parent/carer); BCDH, IKJRH, KBDH, NCMCH, MDH, SDH, JODH: “I was informed and examined in a private area” (adolescents 12-18 years old); page 14 TDH, IADH: “I (child) was not informed in private area, but examined in a private area” (adolescent 15 years old, child parent/carer); TOH, IADH, KBDH: “We didn’t have an option to stay in single or double rooms in the hospital” (child parent/carer); TOH: “The child was not informed in a private area and I didn’t know whether he was examined privately” (parent of 6-11 years old child); KBDH, IADH, NCMCH: “Child was not informed and examined in a private area” (parents/carers). The main actions for improvement of children’s right to non-discrimination are: a) Consolidation of children’s right to access health care services without discrimination: All hospitals are encouraged to improve the existing practices and services regarding interpretation and to treat every single child and their parent/carer with respect and equal services. Secondly, all hospitals must reinforce their referral systems with primary care services, schools and other institutions, to ensure that children have access to health care services without discrimination. b) Consolidation of the respect of children’s right to privacy: All hospitals must ensure, to the extent possible, that every child’s right to privacy is respected. This includes the availability of private areas to examine and inform children and parents/carers, to provide children with the possibility to be examined by a doctor of the same gender and the availability of single and/or double rooms. See Annexes 5 and 6, for summary of inputs on Standard 2 by self-evaluation team and children and parents/carers, respectively. Standard 3: Play and Learning All children have opportunities for play, rest, leisure, recreation and their rights to education protected, suited to their age and condition, in spite of their health needs. 3.1. The hospital ensures the right to play for all children without discrimination of any kind. Children’s right to play and learning is one of the rights that show greater need of attention. In 8 hospitals, there is a policy guaranteeing children’s right to play, but only 3 hospitals provided a properly equipped play room for children; and only 1 hospital provides for a Play Specialist to assist children during play. On the other hand, it is encouraging to see that hospitals have started to use play within therapeutic care: in 3 hospitals, health care providers use distraction techniques during procedures and treatments; and in 3 hospitals, health care providers were trained on how to use different forms of play within therapeutic care. In 1 hospital, the use of play during therapeutic care is based on the IMCI guidelines. In 1 hospital, it was mentioned that there are no resources to buy toys. In 6 hospitals, children reported that they had an opportunity to play with other children in the ward; in 4 hospitals, children said they had had the possibility to continue their school work in the hospital; and in 2 cases, children reported that the doctor had used play during procedures and examination. In most hospitals, children’s inputs demonstrate the lack of appropriate spaces and resources, including toys suitable to their age. Some of their inputs are presented below: TOH, KBDH, IADH: “I played with my mother” (6-11 years old); BCDH, IKJRH, KBDH, NCMCH, SDH, JODH: “I had an opportunity to play with girls and boys in the hospital” (children 6-11 years old, adolescent 12-18 years old); NCMCH: “I had an opportunity of going to school in the hospital and I liked it” (child 6-11 years old); page 15 IKJRH: “The doctor was always joking and telling the verses during examination, treatment and procedures” (adolescent 12-18 years old); BCDH, IKJRH, KBDH, IADH, MDH, SDH, JODH: “I didn’t have an opportunity of going to school in the hospital” (all children 6-11 years old, parents/carers); NCMCH: “There was a play room and I had a chance to play in the hospital. However, games there were not for my age”; BCDH: “There is no computer room or sport space in the hospital” (adolescent 18 years old); TDH, KBDH, MDH, TOH, IADH, SDH: all children did not have an opportunity to play, and didn’t have an opportunity of going to school in the hospital (children, parents/carers); IADH: “My child didn’t have an opportunity to play, there was no designated play rooms for children or trained staff in the hospital” (parent/carer). 3.2. The hospital planning takes into account children’s views of what is needed. In 3 hospitals, the opinion of parents/carers and children has been gathered for the improvement of play spaces. None of the children participating in the assessment had contributed to the improvement of play spaces, as far as it was possible to gather. 3.3. The hospital provides complementarily play and educational activities. In 2 hospitals, self-evaluation teams stated that the hospital provides for complementarily play activities. No hospital had a hospital-based school, however children in 4 hospitals reported that they were able to continue their school work whilst in hospital. The main areas identified for the improvement of children’s right to play are:  a) Making available a play room for children: Play and learning have an important role for children’s development and, when in hospital, it is an added value to therapeutic care, which should be recognized. All hospitals should make available a play room or dedicated play space for children. Where hospitals will be preparing the playroom from the beginning, children and adolescents should be able to participate in its preparation and design. The consultation of children and adolescents will contribute greatly to ensure that the playroom will be designed and equipped to meet the needs and expectations of children of different age groups, in particular adolescents, who often feel that they do not have the opportunity for leisure during their stay in hospital. b) Guarantee Play Specialists and other adequately trained staff to accompany children during their stay in hospital: To the extent possible, hospitals should include Play Specialists in routine staff to assist children. Play Specialists play an important role in therapeutic care by preparing play activities in the Play room or by the child’s bedside, helping children to reduce their anxieties, supporting health staff by using play in the preparation of procedures, among other important activities. c) Introduce training of staff on how to use different forms of play within therapeutic care: Medical staff across countries is using different forms of play within therapeutic care to help children during their stay in hospital. Play is used to alleviate anxiety and stress, to enable children to cope with pain and to help in the management and outcomes of procedures. All hospitals are encouraged to provide training for their health staff on how to use different forms of play within therapeutic care. d) Introduce supportive activities such as clown, music, art and pet-therapy: page 16 In addition to play, there are other activities that can support children’s therapeutic care. These may include clown, music, art and pet-therapy, among others. Supportive play activities are used within therapeutic care, as described in the point before. See Annexes 7 and 8, for summary of inputs on Standard 3 by self-evaluation team and children and parents/carers, respectively. Standard 4: Information and participation All children receive information about their health problem, in ways that are understandable to them, can express their views and participate in decision-making about their care and treatment, in a manner consistent with their evolving capacities. 4.1. The hospital ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation. It is encouraging to see that 8 participating hospitals have introduced a hospital policy defining criteria on children’s right to informed consent. At practice level, adolescents in 6 hospitals reported that they received information on consent to treatment and were able to give consent. Self-evaluation teams in 8 hospitals reported that explanation to parents/carers and children about the medical situation is ensured and, in the majority of hospitals, children and parents/carers reported a positive feedback on the right to information. This included explanations about why the child was sick, his/her medical condition and the possibility to ask questions. Children and parents/carers also reported that health care workers introduced themselves and wore name badges. A smaller amount of children and parents/carers declared that this right was not respected. Some of children’s and parents/carers’ inputs are presented below: TOH, BCDH, IKJRH, KBDH, NCMCH, MDH, SDH, JODH: “Doctor explained to me why I am sick. I understood what he said. I was given information about my sickness and the treatment” (6-11 years old – 10 children; adolescent 12-18 years old, parents/carers); TOH, IKJRH, KBDH, SDH, JODH: “We received enough information about the medical condition of the child and we were informed about possibility to ask questions” (adolescent 12- 18 years old, parent of child 6-11 years old); TDH, BCDH, IKJRH, KBDH, IADH, NCMCH: “I was given verbal recommendations about keeping myself healthy and the information was useful” (adolescents 12-18 years old, parents/carers); TDH, BCDH, IKJRH, KBDH, NCMCH, MDH, SDH, JODH: “I was informed that I could ask health professional questions, and tell medical workers how I was feeling, my thoughts and opinions have been listened to” (adolescents 12-18 years old, parents/carers); TDH: “I understood everything that was said by health staff” (adolescent 15 years old); BCDH, IKJRH, KBDH, NCMCH, MDH, SDH, JODH: “Health care workers introduced themselves and had name badges” (adolescents 12-18 years old, parents/carers); TOH, IADH: “Nobody informed my child about the right to express views freely and I didn’t know whether anybody asked his consent to treatment” (parents/carers of child 6-11 years old); TDH: “Nobody told me why I came to the hospital” (child 7 years old); IADH: “Doctor didn’t explain me why I got sick” (child 6-11 years old); IADH: “I don’t think that we have received enough information from health care workers about the medical condition of child and I was not informed about possibility to ask questions” (parent/carer); TDH: “I didn’t understand what doctor said” (child 7 years old). 4.2. The hospital ensures that all appropriate staff has the skills to engage with dialogue and information-sharing with children of all ages and maturity. As far as it is possible to gather, health staff has no specific training on how to engage in dialogue and information-sharing with children of all ages and maturity. As demonstrated above page 17 by children’s and parents/carers’ inputs, a great part of health professionals are effectively communicating with children, however there is also a part of children who were in hospital, who were not informed about their condition, did not understand the information given and were not adequately involved in a dialogue. Children’s right to information is an essential component of their right to health and all doctors and nurses should be able to fulfil it. 4.3. The hospital engages with children for the development and improvement of health care services. It is very encouraging to see that there is engagement of children for the development and improvement of health care services through their periodic questioning. In 3 hospitals where children are engaged, it was reported that they receive feedback about the outcomes of the survey and in 4 hospitals self-evaluation teams declared that children’s participation influences decision-making in relation to the improvement of health care services. Finally, both self- evaluation teams and children and parents/carers reported a functioning complaints’ system. The main areas for improvement for the respect of children’s right to information and participation are: a) Ensure the respect of every child’s right to information: Children’s right to information and participation is essential to their health education and well-being. Children of all ages should be informed, in accordance to their evolving capacities. All hospitals must ensure that every child receives the same care and this includes the respect of their right to information. Health professionals should be able to explain fully to children about their condition, including what is happening to them, which treatments are proposed, options that are available, implications of all the options, treatment side effects, likelihood of discomfort and how to give ‘bad news’. Children and parents/carers should also receive general health promotion-related information and key information about the child’s stay in hospital. Oral information should be complemented with written information in different formats. b) Providing awareness raising and continuous training for staff on the importance of communicating with children of all ages and how to do this (skills): In order to ensure that all children receive the same type of information, hospitals should train medical staff on the importance of communicating with children and providing an enabling environment for parents/carers and children of all ages. This is essential to provide children and parents/carers with the necessary information, creating trust between professionals and patients, facilitating children’s participation in health decisions, but also in reducing both parents/carers’ and children’s anxiety, ensuring their understanding of and compliance with treatments and enjoyment of an overall positive hospitalization experience. Medical staff should also be aware of existing legislation and policy and be encouraged to implement them. c) Consolidating the implementation of children’s right to informed consent: In hospitals where policy does not yet exist, a hospital policy on informed consent should be adopted by all hospitals, laying out the criteria and establishing an age from when children are able to give their informed consent. Children and parents/carers alike should be supported by health professionals, in order to understand the nature and consequences of the treatment, as well as, the consequences if they refuse that same treatment and therefore be able to make a sound judgment. page 18 Where children cannot give informed consent to treatment, they should still receive information about their situation, be able to ask questions and contribute to the decision- making process. d) Enhancing children’s participating in the improvement of health care services: As it is possible to demonstrate in the present project, children of different age groups can provide important information about how the services are being implemented, in the identification of good practices and gaps, as well as, patient expectations about the services being provided to them. Any consultation with children must guarantee that they are treated with respected, explained the aims of the evaluation or project, how their views will be used and that they receive information about the outcomes of the consultation. Consultations with children can be done either at health service level (i.e. in primary care facilities or hospitals) or at national level (i.e. in schools). Children can provide key information about health challenges, behaviours and risks; health issues influenced by gender-based differences, cultural norms and socioeconomic status; and needs and expectations of services. This information can be used to inform States and health providers in the planning and implementation of effective health programmes and services. See Annexes 9 and 10, for summary of inputs on Standard 4 by self-evaluation team and children and parents/carers, respectively. Standard 5: Safety and environment All services for children are provided in an environment designed, furnished, staffed and equipped to meet their needs. Safety also includes aspects of cleanliness and food. 5.1. The hospital infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs. In 7 hospitals, self-evaluation teams stated that the infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs. Children in 4 hospitals stated that the infrastructure meets children’s mobility needs and in 4 hospitals that it does not. In BCDH hospital, an adolescent aged 18 said that “the hospital should have a modern equipment not to go far away for tests like magnetic resonance image and other examinations”. In 5 hospitals, self- evaluation teams highlighted the need to ensure that equipment and materials follow safety norms. Children’s inputs are presented below: BCDH, KBDH, IADH, NCMCH: “If I have mobility restrictions I would be able to move around all areas of the hospital easily” (adolescent 12-18 years old, parents/carers); TDH, MDH, SDH, JODH: “If I have mobility restrictions I wouldn’t be able to move around all areas of the hospital easily or I don’t know” (adolescents 12-18 years old); 5.2. The hospital policies and practice support the best possible nutrition for children. It is encouraging to see hospitals’ practices in fulfilling children’s right to food. All participating hospitals provide free food for children of most age groups and in all except 1, the menu is prepared by a nutrition specialist. In all hospitals, children stated that: “I (child) timely received free food in the hospital and the food was healthy and tasty”. 5.3. The hospital policies and practices ensure effective and strict cleaning services. It is encouraging to see that all hospitals promote effective cleaning services and that children and families are satisfied by the services provided. All hospitals ensure effective cleaning services and encourage staff to follow strict cleaning procedures. In 10 hospitals, children and parents/carers and carers stated that: “It is clean in the hospital and medical workers always have cleaned hands”. page 19 The main improvements identified for the improvement of this standard are: a) Ensuring that hospitals’ infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: Both the self-evaluation teams and children and parents/carers reported that improvements must be undertaken to ensure that hospitals’ infrastructures meet children’s safety and mobility needs. Consulting with children of different age groups and needs is an effective way of ensuring that the hospitals’ infrastructure is appropriate to all children visiting and staying in the hospital. b) Consolidating children’s right to food: Children’s nutrition is a fundamental component to their well-being and development. All hospital musts continue their good practices in providing nutritious food at appropriate times. c) Ensuring the efficiency of cleaning services and practices: All hospitals are encouraged to continue to maintain high standards of cleaning services and practices. See Annexes 11 and 12, for summary of inputs on Standard 5 by self-evaluation team and children and parents/carers, respectively. Standard 6: Protection Children are protected from all forms of physical or mental violence, unintentional injury, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse. 6.1 The hospital has in place a system that ensures protection of the right of the child against all forms of violence. The inputs from the self-evaluation teams show significant attention to the right of children to be protected from all forms of violence. In 9 hospitals, there is a policy in place on the protection of children who have been victims of any kind of abuse or violence; and in 10 hospitals there are existing referral mechanisms with the local police, social services and other authorities. The only question presented to children in the assessment of this right was: “Do you feel safe in the hospital?” All children, adolescents and parents/carers responded that they felt safe in the hospital. One parent in IADH hospital stated that: “It should be special service for counselling with psychologists in case of any kind of abuse of child”. 6.2. The hospital ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse. In 5 hospitals, health professionals were trained on how to identify and examine children who have been abused and on existing protocols and referral mechanisms based on a handbook and in 1 hospital, health professionals were partially trained. 6.3. Clinical research and trials are strictly regulated by hospital policy. The evaluation of children’s right not to be submitted to clinical research or experimentation projects and to have the possibility to withdraw during the process of research shows that more attention must be paid to the implementation of this right. Although 6 hospitals have adopted protocols regulating children’s participation in clinical research and trials, in 3 hospitals there is page 20 no practice on informed consent to research and in 3 hospitals children and families only partly have the option to refuse or not to be involved in teaching activities of the hospital. The main improvements towards the respect of the right to protection from all forms of violence are: a) Consolidation of the existing system of child protection in all hospitals: The major gaps identified in the respect of this right were: the lack of a team or unit within the hospital dealing with child-protection issues (7 hospitals); staff training in relation to specific child protection issues (5 hospitals); and the assessment of services (4 hospitals). The effective protection of children, once they reach a hospital, depends on a number of services being available to them, within a functioning system. Where missing, all hospitals are invited to adopt a specific hospital policy on child protection, to have in place referral systems with relevant authorities and to regularly monitor and evaluate the system in order to ensure its effectiveness. The medical staff must receive training and be able to identify a child, who has been a victim of abuse and how to treat them, but also to know applicable legislation, hospital policy and how to activate the necessary mechanisms, such as referral systems. b) Ensure that no clinical research and trials are carried out without adequate regulations: All hospitals must ensure that any clinical research and trials carried out within the hospital are clearly regulated by and follow national legislation and hospital policy. Medical staff conducting the research should be made aware of the existing protocols and procedures. To ensure that research complies with national and hospital protocols and regulations, a hospital body should established, such as an Ethics Committee. c) Ensure the protection of every child participating in clinical research or trials: Children participating in clinical research and trials and their parents/carers should be properly informed about what the research entails, their informed consent should always be requested and they should be given the option to refuse or not to be involved in the teaching activities of the hospital and/or to drop out of the research at any time. Furthermore, medical staff must make sure that children and parents/carers understand all these issues, including their option not to participate in the research. See Annexes 13 and 14, for summary of inputs on Standard 6 by self-evaluation team and children and parents/carers, respectively.   Standard 7. Pain management and palliative care All children have the right to individualised, culturally and age appropriate prevention and management of pain and palliative care. 7.1. The hospital policy ensures the prevention and management of pain. The assessment of children’s right to pain management shows that more attention should be given to this right. Only 4 hospitals have adopted/developed protocols and procedures for the prevention and management pain. In 3 hospitals there is a Pain research unit or equivalent, staff receive continuous training in pain management and there are audits to assess the performance of pain management care. Children in most hospitals had been asked by health professionals whether they felt pain and were given medicines for pain relief. Some of children’s and parents/carers’/carers’ inputs are presented below: page 21 TOH, BCDH, KBDH, BCDH, IADH, NCMCH, MDH, SDH, JODH: “I (child) felt pain in the hospital and doctors, nurses and parents/carers asked me whether I feel pain, and they helped me to ease the pain “ (6-11 years old) – 6 children, adolescents 12-18 years old., and parents/carers); BCDH, NCMCH: “I (child) was given medicine for pain relief, and psychological support to make me feel more comfortable” (adolescent 18 years old, parent-carer); BCDH: “Health care workers asked me about whether I feel pain” (adolescent 18 years old); TOH: “Nobody asked me about whether I felt pain” (6-11 years old); TDH, MDH, JODH: “I was given medicine for pain relief, but nothing else to make me feel more comfortable” (adolescents 12-18 years old); IADH: “Child was given medicine for pain relief, but nothing else to make him feel more comfortable, no psychological support” (parent/carer). 7.2. The hospital’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness. In comparison to pain management, more attention was shown in regards to palliative care, which begins when the illness is diagnosed in 6 hospitals. In 7 hospitals, palliative care included psychological support to the child’s family, 5 hospitals provide training to staff on the care of the dying child and ways to communicate the death of a child to family members and in 8 hospitals religious support is provided to families of all faiths. The main areas for improvement identified are: a) All hospitals should adopt pain management protocols: The hospitals that have not yet adopted pain management protocols, based on national or international guidelines are encouraged to do so. Accordingly, a functioning pain management system will entail that a number of practices are carried out, including a system to assess and register children’s pain, training of staff in pain management and regular assessment of services, to ensure that they are implemented effectively. Children’s views should be sought when assessing pain services. b) Introduce an initial and continuous training programme for health care staff in the area of pain management: Medical staff in all hospitals should be trained in the area of pain management, including how to assess and register children’s pain, how to manage painful procedures; and ways to alleviate pain, including alternatives to pain medicine and parents/carers’ support and involvement during procedures. c) Set up a Unit for Psychological/ Psychiatric Support within hospitals for hospitalised children and their families and to children in the community: Both self-evaluation teams and children and parents/carers identified the need to set up a unit for Psychological/Psychiatric support within hospitals. This unit should support hospitalised children and families, as well as, other children in need in the community. The availability of this unit to children in the community must include measures to reach out to children in need of support. d) Build partnerships to provide palliative care in the community services or at home: Establishing partnerships between hospitals and services in the community is essential to prevent unnecessary hospitalization of children. This may be particularly important for children in vulnerable situations, such as children receiving palliative care. Hospitals may build partnerships with primary care level services or other governmental or page 22 nongovernmental organizations working at the community level. Upon existence of the partnership, medical staff should be made aware of it and be able to facilitate the service to children, by referring them. See Annexes 15 and 16, for summary of inputs on Standard 7 by self-evaluation team and children and parents/carers, respectively.   Part 3: Analysis of the assessment results in hospitals in Tajikistan Standard 1: Quality services for children All services provided to children aim at delivering the best quality possible care, by taking into account clinical evidence available, the respect of children’s rights and patient and family’s views and wishes. 1.1. The hospital ensures that all institutional activities are based on the best evidence available and that staff are adequately trained. The question presented to children and parents/carers for the consideration of this right was: “Do you believe you received the best care possible?” Children and parents/carers in all hospitals stated that they had received the best care and appreciated how they had been cared for by the medical staff. Adolescents in 9 hospitals said: “People I met in the hospital were friendly, they were attentive to my opinion, I was happy with the services provided, good nurse, confidentiality was respected in all aspects of treatment and care”. The self-evaluation teams stated that in all hospitals, the care delivered is based on national and international guidelines. However, the assessment of QoC demonstrated that case-management does not follow national or international guidelines and that most of the medical workers are not acquainted with national clinical protocols. As highlighted in the QoC assessment, this is of vital importance: “the experts revealed cases of suboptimal care with significant health hazards, omission of evidence-based interventions, use of diagnostics and treatment methods that are considered ineffective according to international standards and also potentially harmful to children”. Inputs from the self-evaluation teams show that in 7 hospitals, doctors were trained in paediatric care and in 1 hospital the doctors are graduates of Paediatrics. Only in 1 hospital, nurses have training in paediatrics. 1.2. The hospital ensures that all types of services provided within the organization are regularly monitored and evaluated. The self-evaluation teams in all hospitals stated that the services are regularly audited. However, the QoC assessment showed that no proper auditing is performed in the hospitals. Self-evaluation teams declared that in 5 hospitals, patient satisfaction surveys are carried out. Parents/carers and adolescents had mixed experiences. In 10 hospitals, adolescents participated in surveys and in 8 of those same hospitals, parents/carers and adolescents aged 12-18 stated “I didn’t participate in a patient satisfaction survey and nobody asked my or child’s opinion about health care services in the hospital”. 1.3. The hospital has a Charter on Children’s Rights in Hospital, in line with the United National Convention on the Rights of the Child. No hospital had adopted, disseminated and implemented a Charter on Children’s Rights in Hospital, at the time of the assessment. However, based on the inputs of the self-evaluation teams, mainly management, a Charter on Children’s Rights in Hospital was adopted in 6 hospitals and partially adopted in another 1. 3 hospitals have also displayed the Charter in the page 23 hospital wards. Parents/carers and children in 4 hospital stated that they had seen information display in the department and in 9 hospitals declared that no written information was made available to them. See Summary Chart 4 for detailed information per hospital.  Summary Chart 4. Status of adoption and implementation of a Charter of Children’s rights in hospitals in Tajikistan Hospital  Has a Charter  on Children’s  Rights been  adopted?  Is the charter  displayed?  OTHER RELEVANT INFORMATION  KTRH  No  No  However, based on inputs from the self‐ evaluation teams (management input) the own  version of a Charter on Children’s Right was  adopted, but not displayed in the walls of  paediatric departments  CDHJ  No  No  Based on inputs from the self‐evaluation teams  (management input) a Charter on Children’s  Right was not adopted and not displayed in the  walls of departments  CDHR  No  No  However, based on inputs from the self‐ evaluation teams (management input) the own  version of a Charter on Children’s Right was  adopted, and displayed in the walls of  departments  CDHVa  No  No  However, based on inputs from the self‐ evaluation teams (management input) a Charter  on Children’s Right was partly adopted, but not  displayed in the walls of departments  CDHP  No  No  However, based on inputs from the self‐ evaluation teams (management input) a Charter  on Children’s Right was adopted, but not  displayed in the walls of departments  CDHH  No  No  However, based on inputs from the self‐ evaluation teams (management input) a Charter  on Children’s Right was adopted, but not  displayed in the walls of paediatric and delivery  departments  CDHF  No  No  However, based on inputs from the self‐ evaluation teams (management input) a Charter  on Children’s Right was adopted and displayed in  the walls of paediatric and delivery departments  CDHVo  No  No  Based on inputs from the self‐evaluation teams  the hospital didn’t adopt a Charter on Children’s  Right and it was not displayed in the walls of all  wards  CDHK  No  No  Based on inputs from the self‐evaluation teams  the hospital didn’t adopt a Charter on Children’s  Right and it was not displayed in the walls of all  page 24 wards  CDHY  No  No  Based on inputs from the self‐evaluation teams  the hospital adopted a Charter on Children’s  Right and it is displayed in the walls of all wards  1.4. The hospital provides for the possibility for parents/carers to stay with their child at all times during hospitalization. All hospitals allow parents/carers to stay with children, including overnight stay, although with some limitations, such as when there is insufficient room available and the child’s age. In 9 hospitals parents/carers are allowed to stay with children during procedures, including anaesthesia induction in some hospitals. The feedback of children and parents/carers regarding this right was mostly very positive. Children in 9 hospitals said that their parents/carers had stayed with them overnight and stayed with them during procedures. Some of the children’s inputs are presented below: KTRH, CDHJ, CDHR, CDHF, CDHY, CDHVa, CDHVo, CDHP, CDHK: “Parents/carers stayed with me in the ward, including overnight. I feel comfortable when my mother always with me” (children 6-11 years old, adolescents 12-18 years old). CDHJ, CDHR, CDHF, CDHY, CDHP, CDHK: “Relatives stayed with me in the hospital including presence during procedures (adolescents 12-18 years old); KTRH: “Parents/carers didn’t stay with me during procedures, but I wanted them to be with me” (adolescent 12-18 years old); CDHH, CDHVo: “I didn’t want my parents/carers to stay with me and they didn’t stay with me overnight, but they stayed with me during procedures and operation” (adolescent 12-18 years old); Parents/carers participating in the assessment in 5 hospitals had been provided free food. In 6 hospitals, self-evaluation teams reported that no meals are provided for parents/carers. 1.5. The hospital pays special attention to the rights of adolescents to health care. 4 hospitals have an Adolescent Friendly Health Service and in 2 hospitals there is a centre for adolescents seeking to receive confidential counselling. The main areas for improvement of this standard are: a) Ensure that hospital care delivered to children is based on evidence-based national and/or international guidelines: The care delivered by health professionals in hospitals should be based on evidence- based national and/or international guidelines. Where missing, the Ministry of Health should adopt clinical guidelines and protocols to guide hospitals in case-management and in essential aspects of children’s right to health, including establishing criteria for children’s informed consent; confidential services for adolescents; establishing a ‘paediatric age’; among other. The clinical guidelines and protocols will then have to be made available to all hospitals and medical staff working with children. The protocols should be applied by medical staff in daily practice and their implementation should be monitored. Where necessary, the Ministry of Health should allocate budgets for the implementation of guidelines and protocols. b) Ensure effective monitoring and evaluation systems: An adequate system for planning, monitoring and evaluation is essential to the effective functioning of a hospital and to the rational use of budgets. Services must prepare instruments to assess all aspects of service delivered to children. The tools used for this project are an example of tools to assess children’s rights in hospital. page 25 Children’s medical charts are also a useful mechanism to register and assess the care delivered to children. Services in place must correspond to those most needed by children. Regional/national hospitals should promote knowledge sharing, including good and inexpensive interventions that have proven effective to solve common challenges. Importantly, hospitals’ practices must be standardised in order to ensure equal services for children, which includes the existence of hospital policies, training of staff and monitoring of services delivered. Monitoring and evaluation must inform continuously planning and improvement of care delivered to children. Where available, hospitals are encouraged to use Information Technology systems, because it makes data gathering simpler, more efficient and easy to analyse. c) Increase attention to patient satisfaction: All hospitals should promote regular patient satisfaction surveys and/or consultations with children. Patients’ and parents/carers’ views are an important and easy-to-access vehicle for hospitals to identify what is working and what is missing in health care provision. Where hospitals are planning to renovate, it is advisable to consult with children and parents/carers that have used the facilities to understand what services are needed and how they are best delivered. Patient satisfaction surveys may be carried out during or at the end of children’s stay in hospital or once they have returned home. Nowadays, there are a number of user-friendly formats, enabling children of all ages and with learning disabilities to participate and express their views on the care received. Children should always be adequately informed about the survey or programme they are contributing to and should receive feedback on how their views were used. d) Adoption, dissemination and implementation of a Charter on Children’s Rights in Hospital: All hospitals are encouraged to adopt a Charter on Children’s Rights in Hospital. The hospitals that started this process after this assessment should continue the work by displaying the Charter in every hospital ward, making it available to children and parents/carers and training the health staff on how to implement the Charter. The health professionals that have participated in the assessment will have gained knowledge on the meaning of children’s rights and how to implement them in daily care. They should be encouraged by hospital management to apply their knowledge and pass it on to others. e) Enable at least 1 parent to stay with their child, including overnight stay: Hospitals should create the conditions for at least 1 parent to be allowed to stay with their child overnight for free and during procedures; and that all children receiving care have the same rights and benefits. Hospitals are promoting parents/carers’ stay during procedures because it can help to reduce children’s anxiety, by providing comfort to them; parents/carers can often support medical staff in preparing children or helping in procedures; and it may help parents/carers to better understand their child’s condition and how to treat them at home, where applicable. f) Establishing Adolescent Friendly Health Services: page 26 All hospitals should provide Adolescent Friendly Health Services, either independently or in partnerships with primary care level facilities and/or organizations based in the community. In order to reach out to adolescents, hospitals must be aware of the community they are serving, in order to tailor the services to better meet their needs. Services should be particularly aware of adolescents’ right to privacy and counselling, with respect to advice and counselling on health matters; access to sexual and reproductive health programmes; and reaching out to groups of adolescents that may be particularly at risk, including adolescent mothers/parents and adolescents with disabilities, among others. See Annexes 17 and 18, for summary of inputs on Standard 1 by self-evaluation team and children and parents/carers, respectively.   Standard 2: Equality and non-discrimination All children should be able to access health care and undergo any type of treatment without discrimination of any kind, irrespective of the child’s or his or her parents/carers’ or legal guardian’s race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. 2.1. The hospital fulfils the rights of access of all children without discrimination of any kind. All hospitals have adopted policies and practices to ensure that children have the right to access health care services without discrimination. From what is possible to gather, these policies relate mainly to the respect of children’s cultural differences and needs however, the accessibility of services without discrimination entails that a number of services are in place. Specifically, it is important to draw attention to the issue of payments, which was raised in the assessment of QoC. In the hospitals assessed there are no free of charge drugs and according to the interviews with parents/carers, they are paying for all of children’s medications and supplies, including those in the Intensive Care Unit. Furthermore, “as a result of discussion with parents/carers and medical workers, it was revealed that about 85% of drugs procured by parents/carers are officially available free of charge in the respective hospitals.” Health care services should be provided to all children, irrespective of their family’s possibility to pay for services. 2.2. The hospital delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents/carers. All hospitals provided training to staff on how to respect cultural differences. Culturally competent staff is available in 7 hospitals; in 8 hospitals most staff are fluent in 3 common languages used in the country and in 4 hospitals, interpreters are provided, if needed. Adolescents and parents/carers in all hospitals declared that they felt treated with respect. In 1 hospital, a 13 year old-adolescent stated “I am Uzbek and I felt that I was treated the same as everyone else here. Hospital staff spoke Uzbek to me”. Adolescents in 2 hospitals declared that they had not been offered an interpreter. 2.3. The hospital ensures the respect of children’s privacy at all times. Inputs from the self-evaluation teams and children and parents/carers demonstrate that there is some attention to children’s right to privacy. In 7 hospitals, children may be examined by a doctor of the same gender. In 6 hospitals there are private areas for examining children (inputs from self-evaluations teams) and in 7 hospitals children were effectively examined in a private area (inputs from children and parents/carers). 4 hospitals have private areas where they give information to parents/carers and children. Some of the children’s and parents/carers’ inputs are presented below: page 27 CDHR, CDHF, CDHVo, CDHP, CDHK: “Yes, I (my child) had an opportunity to be examined by the doctor of the same gender. In our hospital you can be examined by the doctor who you select” (adolescent 12-18 years old, parent/carers); KTRH, CDHR, CDHF, CDHY, CDHVa, CDHVo, CDHP: “We were informed and examined in a private area” (parent/carers, adolescents 12-18 years old); KTRH, CDHJ, CDHH, CDHF: “I (child) was not informed in private area, but examined in a private area” (adolescent 12-18 years old, child parent/carer); CDHK: “I was informed in admission department and was not examined in a private area (no rooms) (adolescent 12-18 years old); The main areas for improvement of this standard are: a) Ensure that no child has to pay for the treatment received in hospital: The State should abolish user fees, to guarantee that no child in need of receiving hospital care is prevented from accessing treatment on the basis of their economic affordability. If this right is already protected by legislation, the Ministry of Health should guarantee that no out-of-pocket payments take place in hospitals, by making all levels of services and medical staff accountable. b) Consolidation of children’s right to access health care services without discrimination: As it is possible to see, there is attention to this right, not only at policy level, but at practice level, too. All hospitals are encouraged to keep good standards of care, by providing continuous training of staff and encouraging an environment where all children and parents/carers are treated with respect and provided the same care. c) Consolidation of children’s right to privacy: All hospitals must ensure that children’s right to privacy is progressively respected. This includes the availability of private areas to examine and inform children, to provide children with the possibility to be examined by a doctor of the same gender, should they wish to, and the availability of single/double rooms upon request, to the extent possible. See Annexes 19 and 20, for summary of inputs on Standard 2 by self-evaluation team and children and parents/carers, respectively.   Standard 3: Play and Learning All children have opportunities for play, rest, leisure, recreation and their rights to education protected, suited to their age and condition, in spite of their health care needs. 3.1. The hospital ensures the right to play for all children without discrimination of any kind. Inputs from both the self-evaluation teams and children and parents/carers demonstrate that very little attention is paid to this right. Only 2 hospitals have a policy on the right to play and only in 1 hospital, a playroom is available to children. On the other hand, it is encouraging to see that play has been introduced in therapeutic care in 3 hospitals. Adolescents in 8 hospitals were allowed to use their laptops and mobile phones. Especially in hospitals where there are no facilities for children of all ages to play or entertain themselves, this is a good hospital practice, as it enables adolescents to relax during their stay in hospital and to be in contact with their family and friends. Some of children’s and adolescents’ inputs are presented below: page 28 CDHR: “Health care staff helped me to play, they asked my opinion about games, also they played with me during procedures and treatment” (adolescent 12-18 years old); KTRH: “I had an opportunity to play having my own toys, there was a play room for children, however the games in the hospital were not relevant to my age, nobody asked my opinion about games” (adolescent 12-18 years old); KTRH: “I was able to continue my school work in the hospital, my school teacher visited me in the hospital” (adolescent 12-18 years old); CDHF, CDHVo: “Health care personnel uses diversionary tactics while making examination and procedures” (parent/carer). KTRH, CDHJ, CDHF, CDHY, CDHVa, CDHVo, CDHP, CDHK: “(There is) no place to play, no people to help in the hospital, nobody were interested to find out our opinion. There are no conditions for games, no toys, no entertainment activities; we just stayed in the ward. No specialist to help, just nurse who was not trained in that aspect. It would be good to have a play room and toys for children in the hospital” (parents/carers, adolescents 12-18 years old). All hospitals should recognize the importance of play for children, both for their development and in therapeutic care; and therefore commit themselves to respect children’s right to play. 3.2. The hospital planning takes into account children’s views of what is needed. No information to report. 3.3. The hospital provides complementarily play and educational activities. No information to report. The main areas identified for the improvement of children’s right to play are: a) Making available a play room for children: All hospitals should make available a play room or dedicated play space for children. Where hospitals will be preparing the playroom from the beginning, children and adolescents should be able to participate in its preparation and design. The consultation of children and adolescents will contribute greatly to ensure that the playroom will be designed and equipped to meet the needs and expectations of children of different age groups, in particular adolescents, who often feel that they do not have the opportunity for leisure during their stay in hospital. b) Guarantee Play Specialists and other adequately trained staff to accompany children during their stay in hospital: To the extent possible, hospitals should include Play Specialists in routine staff to assist children. Play Specialists play an important role in therapeutic care by preparing play activities in the Play room or by the child’s bedside, helping children to reduce their anxieties, supporting health staff by using play in the preparation of procedures, among other important activities. c) Introduce training of staff on how to use different forms of play within therapeutic care: Medical staff across countries is using different forms of play within therapeutic care to help children during their stay in hospital. Play is used to alleviate anxiety and stress, to enable children to cope with pain and to help in the management and outcomes of procedures. d) Introduce supportive activities such as clown, music, art and pet-therapy: page 29 In addition to play, there are other activities that can support children’s therapeutic care. These may include clown, music, art and pet-therapy, among others. Supportive play activities are also used within therapeutic care, as described in the point before. See Annexes 21 and 22, for summary of inputs on Standard 3 by self-evaluation team and children and parents/carers, respectively.   Standard 4: Information and Participation All children receive information about their health problem, in ways that are understandable to them, can express their views and participate in decision-making about their care and treatment, in a manner consistent with their evolving capacities. 4.1. The hospital ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation. Self-evaluation teams in 6 hospitals stated that children are informed about their right to express their views freely and in 6 hospitals parents/carers are explained their child’s situation. 8 hospitals have adopted policies outlying criteria on children’s informed consent. Inputs from children and parents/carers show a mixed picture on the right to information (children being informed and not informed); right to informed consent (children being told that they may give their consent to treatment and being able to; and other children in the same hospital, not being able to) and so on. This demonstrates that the respect of children’s right to information and participation may be dependent on the awareness of staff and; while there is a policy, some staff may be more aware or equipped to inform and ask children for their informed consent then other. The QoC assessment showed that “at discharge, parents/carers usually receive a short, vague extract without clear recommendations and missing important information.” Children’s and parents/carers’ inputs present good evidence to how the right to information and participation is implemented across hospitals: KTRH, CDHJ, CDHR, CDHH, CDHVa, CDHVo, CDHK: “I was given verbal recommendations about keeping good health of my child and the information was useful” (parents/carers, adolescent 12-18 years old); KTRH, CDHJ, CDHR: “I was informed about the possibility to give informed consent to treatment and I’ve given consent for treatment” (adolescent 12-18 years old, parents/carers); KTRH, CDHJ, CDHR, CDHH, CDHF, CDHY, CDHVa, CDHVo, CDHP, CDHK, CDHK: “Doctor explained to me why I got sick. I understood what he said. I believe I was given enough information about my sickness and the treatment” (adolescents 12-18 years old); KTRH: “Doctor explained to my parents/carers about my disease, nurses explained to me what to do to prevent sickness” (child 6-11 years old); KTRH, CDHR, CDHH, CDHF, CDHY: “Nobody informed me about the right to express views freely, but I could ask questions to health care staff” (adolescent 12-18 years old, parents/carers); CDHY, CDHVa: “I didn’t understand everything the doctor said to me about my health status and treatment, it was not enough information” (adolescent 12-18 years old); CDHR: “I was informed about the possibility to give informed consent to treatment, but nobody asked our consent to treatment” (parents/carers of child 6-12 years old). In 6 hospitals, there is a system in place where children and adolescents can voice concerns about their health care and in 4 hospitals, children’s and adolescents’ complaints are always investigated and feedback is provided. In 3 hospitals children said “I do not feel comfortable to speak about what I did not like in the hospital because they cured me”. In many countries, presenting complaints is not part of the culture and may often be seen as something negative, rather than constructive. In the hospital setting, it is very important to have feedback from patients on the services provided, as they are dealing with children’s health. Where there is no page 30 culture of complaining or giving suggestions for change, implementing an effective patient survey and complaints’ system may be even more relevant. 4.2. The hospital ensures that all appropriate staff has the skills to engage in dialogue and information-sharing with children of all ages and maturity. Inputs from the self-evaluation teams show that in at least 6 hospitals, health care providers have not been trained on how to effectively communicate with children and families. As demonstrated above by children’s and parents/carers’ inputs, some professionals are being able to inform children in a way that they understand and others are not able to. Children’s right to information is an essential component of their right to health and all doctors and nurses should be capable to fulfil it. 4.3. The hospital engages with children for the development and improvement of health care services. It is encouraging that at least in 3 hospitals, there is engagement of children for the improvement of health care services. Self-evaluation teams stated that children who participate receive feedback on survey outcomes. The main areas for improvement of children’s right to information and participation are: a) Ensure the respect of every child’s right to information: Children’s right to information and participation is essential to their health education and well-being. Children of all ages should be informed, in accordance to their evolving capacities. All hospitals must ensure that every child receives the same care and this includes the respect of their right to information. Health professionals should be able to explain fully to children about their condition, including what is happening to them, which treatments are proposed, options that are available, implications of all the options, treatment side effects, likelihood of discomfort and how to give ‘bad news’. Children and parents/carers should also receive general health promotion-related information and key information about the child’s stay in hospital. Oral information should be complemented with written information in different formats. b) Provide awareness raising and continuous training for staff on the importance of communicating with children of all ages and how to do this (skills): In order to ensure that all children receive the same type of information, hospitals should train medical staff on the importance of and how to communicate with children and provide an enabling environment for parents/carers and children of all ages. This is essential to provide children and parents/carers with necessary information, creating trust between professionals and patients, facilitating children’s participation in health decisions, but also in reducing both parents/carers’ and children’s anxiety, ensuring their understanding of and compliance with treatments and enjoyment of an overall positive hospitalization experience. Medical staff should also be aware of existing legislation and policy and be encouraged to implement them. c) Consolidating the implementation of children’s right to informed consent: In hospitals where policy does not yet exist, a hospital policy on informed consent should be adopted, laying out the criteria and establishing an age or other condition (i.e. the child’s maturity and capacity) from when children are able to give their informed consent to treatment. Children and parents/carers alike should be supported by health professionals, in order to understand the nature and consequences of the treatment, as well as, the consequences if they refuse that same treatment and therefore be able to page 31 make a sound judgment. Where children cannot give informed consent to treatment, they should still receive information about their situation, be able to ask questions and contribute to the decision-making process. d) Engage regularly with children for the development and improvement of health care services: As it is possible to demonstrate in the present assessment, children of different age groups can provide important information about how the services are being implemented, in the identification of good practices and gaps, as well as, patient expectations about the services being provided to them. Any consultation with children must guarantee that they are treated with respected, explained the aims of the evaluation or project, how their views will be used and that they receive information about the outcomes of the consultation. Consultations with children can be done either at health service level (i.e. in primary care facilities or hospitals) or at national level (i.e. in schools). Children can provide key information about health challenges, behaviours and risks; health issues influenced by gender-based differences, cultural norms and socioeconomic status; and needs and expectations of services. This information can be used to inform States and health providers in the planning and implementation of effective health programmes and services. See Annexes 23 and 24, for summary of inputs on Standard 4 by self-evaluation team and children and parents/carers, respectively.   Standard 5: Safety and environment All services for children are provided in an environment designed, furnished, staffed and equipped to meet their needs. Safety also includes aspects of cleanliness and food. 5.1. The hospital infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs. In general, the assessment of this standard demonstrates difficulties mostly related to budget allocation and/or economic restrictions. Parents/carers and children that participated in the assessment showed a satisfaction with the treatment received, but also called the attention for the great need to renovate hospitals, including having appropriate facilities, such as toilets, a play room, more modern equipment; and ensuring more strict cleaning policies and practices. In 4 hospitals, the self-evaluation teams identified the need to allocate a budget to ensure that a functioning sewerage system is implemented, as well as, air conditioning. The assessment on QoC also found that in 9 hospitals there are no conditions for taking shower and bathing sick children. In 8 hospitals, the available equipment and materials follow safety norms. Parents/carers and adolescents in 6 hospitals stated that the hospital’s infrastructure does not ensure that children with mobility restrictions would be able to move around and access all areas of the hospital. Below are some contributions by children and parents/carers in the assessment of this standard: KTRH, CDHH, CDHP, CDHK: “If I have mobility restrictions I would be able to move around all areas of the hospital with assistance of health care staff” (adolescent 12-18 years old, parents/carers); CDHF: “Health care services and assistance in the hospital should be improved. We live in XXI century. So far my opinion didn’t influence the hospital health care services. I don’t see outcomes. We didn’t participate in formal patient satisfaction survey, I am not happy with health care services” (parent/carers); page 32 CDHJ: “Food is brought from home, no meal (is provided) in the hospital, there is no single wards, no child furniture, no beds, no air conditioning, no play rooms, no toys and games in the hospital. Hospital requires renovation” (adolescent 12-18 years old); 5.2. The hospital policies and practice support the best possible nutrition for children. The inputs from the self-evaluation teams and parents/carers and children complement the information of the assessment of QoC that there are poor conditions for the provision of the best possible nutrition for children. Free food is provided to children in only 5 hospitals and with limitations and in only 2 hospitals the menu is prepared by a nutrition specialist. Some of the inputs by children and parents/carers are presented below: KTRH, CDHF: “I timely received free food in the hospital two times daily, but it would be good to have a variety of menu” (adolescent 12-18 years old); CDHR, CDHH, CDHP: “I (child) timely received free healthy food in the hospital” (adolescent 12-18 years old, parent/carer); CDHH, CDHF: “The food was not healthy and was not timely given, lack of attention in the hospital to this issue” (parent/carer); CDHJ: “Food for children we are bringing from home” (parent/carer); 5.3. The hospital policies and practice ensure effective and strict cleaning services. In 10 hospitals, there are policies and practices in place to ensure effective cleaning services and in 9 hospitals, staff is encouraged to follow strict cleaning procedures. In practice, inputs by children and parents/carers show a mixed picture. Children and parents/carers stated that: KTRH, CDHJ, CDHR, CDHF, CDHY, CDHVa, CDHVo, CDHP, CDHK: “It was clean in the hospital and medical workers always cleaned hands” (adolescents 12-18 years old, parents/carers); CDHH: “It was not clean in the hospital” (adolescents 12-18 years old, parent/carer); CDHR, CDHK: “It is hot and stifling indoor and conditions of the department is not good” (parent/carer, adolescent 12-18 years old); CDHF: “Medical workers not always cleaned hands, hospital requires renovation, it is not clean” (parent/carer). The main areas identified for the improvement of this standard are: a) Ensure the availability of an adequate infrastructure and facilities: All hospitals must ensure that the hospital infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs, including a sanitation system. The State, or hospitals in partnership with other public or private entities, should make a budget available to ensure that all hospitals have a safe infrastructure, a sewerage system and access to safe and clean water. There are also other low-cost, but essential procedures that can and should be implemented. An example of this is cleanliness: children and parents/carers have called the attention for the need to improve cleaning services. This should include in- hospital campaigns to make medical staff aware of the importance of washing hands in the prevention of contagion of illnesses. b) Ensure the best possible nutrition for children while in hospital: Children’s nutrition is a fundamental component to their well-being and development. Hospitals must ensure that food is provided to children while in hospital and that it is adequate, provided free of charge and at appropriate times. Where budget allocation is an issue, hospitals must attempt to ensure children’s right to food by establishing partnerships with community organizations, the private sector, by preparing a hospital garden or creating another solution, that is adequate for the hospital and the patients it page 33 is serving. c) Ensure a clean environment for children at all times: Hospitals’ cleanliness depends on practices and infrastructure. Practices must include clean wards and hospital spaces, clean bed sheets, overall hygienic conditions and practices by health professionals (i.e. always washing their hands before and after examining or treating a child). Infrastructure includes sanitary conditions and clean and safe water. See Annexes 25 and 26, for summary of inputs on Standard 5 by self-evaluation team and children and parents/carers, respectively.   Standard 6: Protection Children are protected from all forms of physical or mental violence, unintentional injury, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse. 6.1. The hospital has in place a system that ensures protection of the right of the child against all forms of violence. The inputs from the self-evaluation teams show significant attention to the right of children to be protected from all forms of violence. In the majority of hospitals there is a child protection system, which includes a hospital policy that staff is aware of (10 hospitals), existing referral mechanisms with the local police, social services and other authorities (8 hospitals), the availability of a system to register and monitor cases of children who have been victims of child abuse (6 hospitals) and an audit system (4 hospitals). 7 hospitals identified the need of a team or unit within the hospital dealing with child-protection issues. 6.2. The hospital ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse or unintentional injury. Medical staff in 4 hospitals has been trained on existing protocols and mechanisms. 6 hospitals have identified the need to train staff in relation to specific child protection issues. 6.3. Clinical research and trials are strictly regulated by hospital policy. None of the participating hospitals in Tajikistan carry out research or clinical trials with children. In 2 hospitals, an Ethics Committee for clinical research and trials has been established. Where hospitals are planning to carry out research or clinical trials with children, they should ensure that: a) No clinical research and trials in carried out without adequate regulations: All hospitals must ensure that any clinical research and trials carried out within the hospital are clearly regulated by and follow national legislation and hospital policy. Medical staff conducting the research should be made aware of the existing protocols and procedures. To ensure that research complies with national and hospital protocols and regulations, a hospital body should established, such as an Ethics Committee. b) The protection of every child participating in clinical research or trials is guaranteed: Children participating in clinical research and trials and their parents/carers should be properly informed about what the research entails, their informed consent should always be sought and they should be given the option to refuse or not to be involved in the page 34 teaching activities of the hospital and/or to drop out of the research at any time. Furthermore, medical staff must make sure that children and parents/carers understand all these issues, including their option not to participate in the research. The main action for the improvement of the respect of the right to protection from all forms of violence is: a) Consolidation of the existing system of children protection in all hospitals: The effective protection of children, once they reach a hospital, depends on a number of services being available to them, within a functioning system. Where missing, all hospitals are invited to adopt specific hospital policy on child protection, to have in place referral systems with relevant authorities and to regularly monitor and evaluate the system in order to ensure its effectiveness. The medical staff must receive training and be able to identify a child, who has been a victim of abuse and how to treat them, but also to know applicable legislation, hospital policy and how to activate the necessary mechanisms, such as referral systems. See Annexes 27 and 28, for summary of inputs on Standard 6 by self-evaluation team and children and parents/carers, respectively. Standard 7: Pain management and palliative care All children have the right to individualized, culturally and age appropriate prevention and management of pain and palliative care. 7.1. The hospital policy ensures the prevention and management of pain. Inputs from both the self-evaluation teams and children and parents/carers demonstrate that there is significant attention given to children’s right to pain management. 8 hospitals have adopted protocols for the management of pain, in 5 hospitals all staff is trained in pain management, audits are undertaken and there is palliative care available, which includes psychological support. Additionally, 1 hospital provides continuous training for staff. Children and parents/carers gave a very positive feedback on this right for all hospitals, with very few exceptions. It is also important to mention that children and parents/carers valued greatly the attentive and caring staff. Some of the children’s and parents/carers’ inputs are presented below: KTRH, CDHH, CDHF, CDHVa, CDHP: “I didn’t feel pain in the hospital, but the nurse always asked me whether I feel pain and helped me” (children 6-11 years old, adolescent 12-18 years old, parent/carer); KTRH, CDHJ, CDHR, CDHY, CDHVa, CDHVo, CDHP, CDHK: “I (child) felt pain in the hospital and doctors, nurses and parents/carers asked me whether I feel pain, and they helped me to ease the pain” (child 6-11 years old, adolescents 12-18 years old, parents/carers); KTRH: “Health staff was saying kind and warm words, trying to help my child, also asked every hour how my child feels” (parents/carers); CDHJ, CDHR, CDHH, CDHP: “My child was offered a psychological support and we received care in accordance with our religious faith” (parent/carer); CDHH: “I didn’t feel pain in the hospital and nobody asked me whether I feel pain” (child 6-11 years old). 7.2. The hospital’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness. There are no specific programmes for a dignified death, but there are some measures in place. In 7 hospitals, religious support is provided. page 35 The main areas for improvement identified are: a) All hospitals should adopt pain management protocols: The hospitals that have not yet adopted pain management protocols are encouraged to do so. Accordingly, a functioning pain management system will entail that a number of practices are carried out, including a system to assess children’s pain, training of staff in pain management and regular assessment of services, to ensure that they are implemented effectively. b) Introduce an initial and continuous training programme for health care staff in the area of pain management and palliative care: Medical staff in all hospitals should be trained in the area of pain management, including how to assess and register children’s pain and ways to alleviate it, including alternatives to pain medicine. The clinical education programme should include care on the dying child and communication of the death of the child to family members. c) Set up a Unit for Psychological/ Psychiatric Support within hospitals for hospitalised children and their families and to children in the community: Both self-evaluation teams and children and parents/carers identified the need to set up a unit for Psychological/Psychiatric support within hospitals. This unit should support hospitalised children and families, as well as, other children in need in the community. The availability of this unit to children in the community must include measures to reach out to children in need of support. d) Build partnerships to provide palliative care in the community services or at home: Establishing partnerships between hospitals and services in the community is essential to prevent unnecessary hospitalization of children. This may be particularly important for children in vulnerable situations, such as children receiving palliative care. Hospitals may build partnerships with primary care level services or other governmental or nongovernmental organizations working at the community level. Upon existence of the partnership, medical staff should be made aware of it and be able to facilitate the service to children, by referring them. See Annexes 29 and 30, for summary of inputs on Standard 7 by self-evaluation team and children and parents/carers, respectively.   Part 4: Common recommendations for hospitals and Ministries of Health in Kyrgyzstan and Tajikistan. Specific actions for improvement of the respect of children’s rights in hospital have been provided throughout this report, for every standard and child right. This final section aims to draw on that analysis and present general guidelines and recommendations for Ministries of Health and hospitals in both participating countries. page 36 Recommendations for the Ministries of Health:  Enact evidence-based national legislation and protocols on key aspects of hospital health care for children, including abolishing user fees for all children (and other access-related issues), criteria for informed consent, pain management, palliative care, common childhood diseases, and other, as necessary;  Ensure the implementation of national legislation and protocols by health care providers by: disseminating the legislation and protocols to hospitals, integrating them in medical curricula and establishing mechanisms for monitoring and evaluation, including a reporting system from hospitals;  Allocate budgets to renovate health infrastructure and supply necessary hospital equipment and drugs. Attention to specific child rights in hospital:  Right to information and participation: States should enhance a national cultural on the respect for the views of the child, including providing relevant health-related information to children in different life settings (home, school, hospital), involving children in decision-making processes influencing their health (including treatment) and consulting with children on the design and improvement of health care services;  Right to food: States should fulfil children’s right to food in hospital, by allocating budgets, facilitating partnerships between relevant organizations and hospitals and/or other measures adapted to the local context;  Right to play: children who experience hospitalization are in a vulnerable situation and foreign environment. As seen throughout this report, play can have a meaningful role in diminishing children’s anxiety and pain, in contributing to their development and within therapeutic care. States should fulfil children’s right to play by allocating budgets, facilitating partnerships between relevant organizations and hospitals and/or other measures adapted to the local context.  Recommendations for the hospitals:  Adopt hospital policies, based on national legislation and protocols;  Disseminate hospital policies’ content to health professionals through training and awareness raising. Training should include theoretical knowledge (i.e. what is the criteria for informed consent?), skills (i.e. how to inform a child and involve s/he in dialogue and decision-making processes, according to their evolving capacities) and practical knowledge (i.e. where to find the form that children should sign in order to give their informed consent). How to activate referral mechanisms is also an essential component of health professionals’ knowledge;  Adopt monitoring and assessment instruments to ensure that hospital policies are implemented effectively. Children and parents should be involved in the assessment, through patient satisfaction mechanisms or periodic consultations. Monitoring and evaluation should be used to inform hospital planning and improvement of health care service delivery;  Hospitals should use budgets effectively, by establishing priorities and creating an accountable system. Attention to specific child rights in hospital: page 37  Right to information and participation: Hospital policy and health professionals in daily practice must ensure an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation, including information about their health and treatment, involving them in the decision- making process; the possibility to give consent to treatment; and participation in the improvement of health care services;  Right to food: Hospitals must ensure the right of every hospitalised child to nutritious food given at appropriate times;  Right to play: Hospitals must undertake to make the necessary provisions for the fulfilment of children’s right to play, including setting up a play room or space for children to play, hiring Play Specialists to assist children, train health professionals how to use play within therapeutic care and engaging with organizations in the community to provide alternative forms of play, such as music, pet and other therapies.   page 38 Annexes Annex 1. Kyrgyzstan – Hospital names and abbreviations N  Abbreviation  Hospital Name    1  TDH  Ton District Hospital  2  JODH  Jety‐Oguz District Hospital  3  BCDH  Balykchi City District Hospital  4  IKJRH  Issyk‐Kul Joint Regional Hospital  5  TOH  Talas Oblast Hospital  6  KBDH  Kara‐Bura District Hospital  7  IADH  Issyk‐Ata District Hospital  8  MDH  Moskovskiy District Hospital  9  BADH  Bakay‐Ata District Hospital  10  NCMCH  National Center of Mother & Child Health  11  SDH  Sokoluk District Hospital  Annex 2. Tajikistan – Hospital names and abbreviations N  Abbreviation  Hospital Name    1  KTRH  Kurgan‐Tube Regional Hospital  2  CDHJ     Central District Hospital Jomi  3  CDHR    Central District Hospital Rumi  4  CDHVa    Central District Hospital Vakhsh  5  CDHP    Central District Hospital Pyandzh  6  CDHH   Central District Hospital Hamadoni  7  CDHF  Central District Hospital Farkhor  8  CDHVo  Central District Hospital Vose  9  CDHK  Central District Hospital Kulyab  10  CDHY  Central District Hospital Yavan   Annex 3. Kyrgyzstan – Standard 1: Quality services for children: inputs from the self-evaluation teams Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   Health care service delivered to  children is based on national and  international guidelines (TDH, JODH,  BCDH, IKJRH, TOH, KBDH, IADH, MDH,  BADH, NCMCH, SDH);   “Those health care providers (doctors  and nurses) who work with children   Not all health care  providers (doctors  and nurses) who  work with children  were trained in  paediatric care  (KBDH, MDH, BADH);   Formally and fully  adopt a Charter on  Children’s Right  (TDH, TOH, KBDH,  MDH, SDH, BCDH);    Educate all health  care service staff  page 39 were trained in paediatric care” (TDH,  JODH, BCDH, IKJRH, TOH, IADH,  NCMCH, SDH);   The hospital adopted a Charter on  Children’s Right (IKJRH, IADH, BADH,  NCMCH);    The Charter on Children’s Right is  displayed in the walls of all wards  (IKJRH – paediatric department, BADH,  NCMCH);   Health care service staff were trained  about the Charter and Children’s Right  (IKJRH, NCMCH);   Hospital facilitate in carrying out of  audit to meet health care services in  line with the organizational policy and  action plan (TDH, JODH, BCDH, IKJRH,  TOH, KBDH, IADH, MDH, BADH,  NCMCH);   The hospital supports regular patient  satisfaction surveys through their  questioning (JODH, IKJRH ‐feedback  book, anonymous box, KBDH, IADH,  MDH, BADH, NCMCH, SDH)   The hospital has an effective system of  patient satisfaction surveys (IKJRH,  IADH, NCMCH),    The hospital adopted a Charter on  Children’s Right in the context of  health care quality for children  (JODH),    The Charter on Children’s Right is  displayed in the walls of all wards  (JODH);   Parents/carers are allowed to stay  with the child during hospital stay  (TDH, BCDH, IKJRH – with children up  to 7 years old, TOH, KBDH, IADH,  MDH, BADH, NCMCH, SDH);   Parents/carers are allowed to stay   Hospital doesn’t  facilitate in carrying  out of audit to meet  health care services  in line with the  organizational policy  (SDH);   The patient  satisfaction surveys  carried out partly or  not carried out (TDH,  BCDH, TOH, KBDH,  BADH, SDH);   The hospital didn’t  adopt a Charter on  Children’s Right  (TDH, TOH, KBDH,  MDH, SDH);   The Charter on  Children’s Right is  not displayed in the  walls of all wards  (TDH, KBDH, MDH,  SDH);   The hospital partly  adopted a Charter  on Children’s Right  (BCDH),    The Charter on  Children’s Right is  partly displayed in  the walls of all wards  (BCDH, TOH),    Not all health care  service staff were  trained about the  Charter and  Children’s Right  (TDH, JODH), TOH,  KBDH, IADH, MDH,  BADH, SDH);   Parents/carers are  (doctors and  nurses) on the  Charter and  Children’s Right;   Improve the  process of setting  and introduction of  an effective system  of patient  satisfaction surveys  (TDH, BCDH, TOH,  KBDH, BADH, SDH);   Facilitate in carrying  out of audit to meet  health care services  in line with the  organizational  policy;   Organize an  adolescent‐friendly  health services in  the hospital and an  adolescent‐friendly  health facility  reaches out to  adolescents  (TDH,JODH, IADH,  NCMCH, BCDH,  TOH, BADH, SDH);   Ensure that  parents/carers are  always allowed to  stay with the child  overnight for free  (TDH);   Ensure that  parents/carers are  allowed to receive  free or subsidized  meals at the  hospital (TDH,  KBDH, IADH, MDH,  NCMCH);    page 40 with the child during procedures,  except anaesthesia induction (JODH,  BCDH, IKJRH);    Parents/carers are always allowed to  stay with the child overnight for free  (JODH, BCDH, IKJRH, TOH, KBDH,  IADH, MDH, BADH, NCMCH, SDH);   Parents/carers are allowed to receive  free or subsidized meals at the  hospital (JODH, BCDH, IKJRH, TOH,  BADH, SDH)   There is adolescent‐friendly health  services in the hospital (BCDH, IKJRH,  TOH, KBDH, MDH, BADH, SDH);   There is school doctor or adolescent‐ friendly health facility who reaches  out to adolescents (JODH, IKJRH,  KBDH, MDH, NCMCH).  not always allowed  to stay with the child  overnight for free  (TDH);   Parents/carers are  not allowed or partly  allowed to receive  free or subsidized  meals at the hospital  (TDH, KBDH, IADH,  MDH, NCMCH);   There is no  adolescent‐friendly  health services in the  hospital (TDH,JODH,  IADH, NCMCH);    There is no or  limited adolescent‐ friendly health  facility reaches out  to adolescents (TDH,  BCDH, TOH, IADH,  BADH, SDH).      Annex 4. Kyrgyzstan – Standard 1: Quality services for children: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   TOH, TDH, BCDH, BADH,  IKJRH, KBDH, IADH,  NCMCH, MDH, SDH, JODH:  “I (child) timely received  free food in the hospital  and the food was healthy  and tasty” (6‐11 years old  child, adolescent 12‐18  years old, parents/carers);   TOH, TDH, BCDH, IKJRH,  KBDH, IADH, NCMCH,  MDH, SDH, JODH: “It is  clean in the hospital and  medical workers always  cleaned hands” (6‐11 years  old child, adolescent 12‐18   IADH: “My child didn’t  receive the best care”  (parents/carers);   IADH: “Advice on child’s  health care support was  given verbally”;   IADH: “I didn’t  participate in patient  satisfaction survey”  (parents/carers);   IADH, TDH, BCDH, TOH,  IADH: “I haven’t  received the copy of the  Charter on Children’s   BCDH: “The hospital should  have a modern equipment  not to go far away for tests  like MRT and other  examinations” (adolescent  18 years old);   Ensure that children and  parents/carers participate in  patient satisfaction surveys  (TOH);   Ensure that the outcomes of  patient satisfaction survey  communicated back to  children and parents/carers  and contribute to the  page 41 years old, parents/carers);   Hospitals (TDH, BCDH,  IKJRH, TOH, KBDH,  NCMCH, MDH, SDH,  JODH): The question  presented to children and  parents/carers for the  consideration of this right  was: “Do you believe you  received the best care  possible”. Children (6‐11  and 12‐18 years old) and  parents/carers responded:  “Yes”.   IADH: “I received the best  care from nurses in the  hospital” (adolescent 12‐18  years old)   IKJRH, TOH, KBDH,  NCMCH, MDH: “I  participated in patient  satisfaction survey and was  informed how the  information would be  used” (adolescent 12‐18  years old, parents/carers);   TDH, IKJRH, KBDH: “I was  asked by medical staff  what I think about the  services and care and also  was explained how the  information would be  used” (adolescent 15 years  old, 12‐18 years old);   TDH: “Health worker  talked with me about my  rights” (adolescent 15  years old);   TDH, BCDH, IKJRH, KBDH,  IADH, NCMCH, MDH, SDH,  JODH: “People I met in the  hospital were friendly, they  were attentive to my  opinion, I was happy with  Right and nobody talked  with me about the  children’s rights”  (adolescent 12‐18 years  old, parent/carer);   SDH: “I haven’t received  the copy of the Charter  on Children’s Right and  haven’t seen the  information, but health  care workers talked  with me about the  children’s rights  (adolescent 12‐18 years  old);   MDH, JODH: “I haven’t  received the copy of the  Charter on Children’s  Right, but I’ve seen the  information about the  rights, health care  workers talked with me  about the children’s  rights” (adolescent 12‐ 18 years old);   KBDH, MDH, SDH,  JODH: “I participated in  patient satisfaction  survey, but not sure  whether it was  contributed to the  decision‐making”  (adolescents 12‐18  years old,  parents/carers);   IADH: “I have seen the  Charter on Children’s  Right on the wall, but  health care workers  didn’t talk with me  about children’s rights”  (adolescent 16 years  old, 12‐18 years old,  parent/carers);   TDH, BCDH, MDH,  decision‐making (KBDH,  MDH, SDH, JODH).   Distribute the copy of the  Charter on Children’s Right  among hospitalised children  and inform them about their  rights.   Ensure that parents/carers  are always allowed to stay  with the child overnight for  free;   Ensure that parents/carers  are always allowed to stay  with the child during  procedures, including  injections, blood extraction.    page 42 the services provided”,  “Confidentiality was  respected in all aspects of  treatment and care  (adolescents 12‐18 years  old);   NCMCH, MDH: “I)child)  was given the copy of seen  the Charter on Children’s  Right and health care  workers talked with me  about my rights”  (adolescent 12‐18 years  old, parents/carers);   BCDH, IKJRH, KBDH, IADH:  “I have seen the Charter on  Children’s Right and health  care workers talked with  me about my rights”  (adolescent 16 years old,  12‐18 years old,  parent/carers);   TOH: “Parents/carers  stayed with me overnight  in the ward” (6‐11 years  old) – 2 children;   TDH, BCDH, IKJRH, KBDH,  IADH, NCMCH, SDH, JODH,  JODH: “Parents/carers  were always with me  during my stay in the  hospital, including  overnight” (children 6‐11  years old, adolescents 12‐ 18 years old, parent/carer);   NCMCH: “I didn’t want my  parents/carers to stay with  me and they didn’t stay  with me, but mother  stayed with me during  procedures” (adolescent  12‐18 years old);   TDH, TOH, BADH, JODH,  BCDH, IKJRH, KBDH, IADH,  JODH: “I didn’t  participate in patient  satisfaction survey”  (adolescent 12‐18 years  old);   The questions  presented to children in  consideration of this  right were: “Did you  participate in survey on  evaluation and  improvement of medical  services?”   TOH: “I did not  participate in any  surveys”    TOH, TDH, IADH, MDH:  “Parents/carers were  not always with me  during my stay in the  hospital and didn’t stay  with me overnight” (6‐ 11 years old, adolescent  15 years old);   TDH: “Parents/carers  didn’t stay with me  during procedures,  including injections,  blood extraction”  (adolescent 15 years  old);   MDH: “Parents/carers  didn’t stay with me in  the hospital though I  wanted them to stay  with me” (adolescent  12‐18 years old);   TOH, NCMCH, MDH:”I  was not allowed to stay  with the child during his  stay in the hospital,  including presence  during procedures, but I  wanted to stay there  page 43 NCMCH, MDH, SDH: “I was  allowed to have my mobile  phone and laptop with me”  (adolescents 12‐18 years  old);   IKJRH: “Parents/carers  were not always with me  during my stay in the  hospital and didn’t stay  with me overnight because  I am a big boy” (7 years  old);   IKJRH: “Parents/carers  were not with me during  my stay in the hospital and  didn’t stay with me  overnight because I am an  adult” (adolescent 11‐18  years old);   TOH, TDH, BADH, IADH,  KBDH, BCDH, IKJRH, JODH,  NCMCH, MDH, SDH:”I was  provided free food whilst  accompanying my child”  (parents/carers).    (parents/carers);   BCDH:”I was allowed to  stay with the child  during his stay in the  hospital, including  presence during  procedures, but was not  allowed to stay  overnight there  (parents/carers).  Annex 5. Kyrgyzstan – Standard 2: Equality and non-discrimination: inputs from the self-evaluation teams Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   There is a hospital policy to  ensure that children of  minority and other status are  not discriminated and have  equal access to health services  (TDH, JODH, BCDH, IKJRH,  KBDH, IADH, MDH, NCMCH,  SDH);   Hospital staff is trained on  respect and care of patients  with cultural differences  (JODH, BCDH, IKJRH, KBDH,  IADH, MDH, BADH, NCMCH,   There is no a hospital  policy to ensure that  children of minority and  other status are not  discriminated and have  equal access to health  services (TOH, BADH);   Hospital staff is partially  trained on respect and  care of patients with  cultural differences (TDH,  TOH);   Develop and endorse a  hospital policy to  ensure that children of  minority and other  status are not  discriminated and have  equal access to health  services (TOH, BADH);    Develop or enhance the  program on continuous  cultural‐competence  training for staff;   Guarantee competent  page 44 SDH);   Hospital policy guarantees  culturally competent staff or  volunteers (TDH, JODH, IKJRH,  IADH, MDH, NCMCH);    Hospital provides qualified  interpreter/volunteer, if  needed (JODH, IKJRH, MDH,  NCMCH);   Children have a choice be  examined by the doctor of the  same gender (TDH, JODH,  BCDH, TOH, IADH, BADH,  NCMCH, SDH);   There is private area for  performing examinations  (TDH, JODH, IKJRH, IADH,  MDH, NCMCH,);   Children can be hospitalised in  single or double rooms, upon  request (JODH, IKJRH, IADH,  NCMCH, SDH);   Children are informed in  private areas (JODH, IKJRH,  MDH, NCMCH, SDH).   Hospital policy doesn’t or  partly guarantee  culturally competent  staff or volunteers  (BCDH, TOH, KBDH,  BADH, SDH);   Hospital does not provide  or partly provide  qualified interpreter  (TDH, BCDH, TOH, KBDH,  IADH, BADH, SDH);   Children have a limited  choice (partly) be  examined by the doctor  of the same gender  (IKJRH, KBDH, MDH);    Children not always can  be hospitalised in single  or double rooms, upon  request (TDH, BCDH,  TOH, KBDH, MDH,  BADH); Children are not  always informed in  private areas (TDH,  BCDH, TOH, KBDH, IADH,  BADH);    Private areas for  examination are not or  not always available  (BCDH, TOH, KBDH,  BADH, SDH).  interpreters, culturally  competent staff or  volunteers;   Ensure that children  have choice to be  examined by the doctor  of the same gender  (IKJRH, KBDH, MDH);   Ensure the right of  children to be  hospitalised in single or  double rooms, upon  request (TDH, BCDH,  TOH, KBDH, MDH,  BADH);    Ensure the right of  children to be informed  in private areas (TDH,  BCDH, TOH, KBDH,  IADH, BADH);    Ensure the right of  children to be examined  in private areas (BCDH,  TOH, KBDH, BADH,  SDH).  Annex 6. Kyrgyzstan – Standard 2: Equality and non-discrimination: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   TDH, BCDH, IKJRH, TOH,  KBDH, IADH, NCMCH, MDH,  JODH: “I (child) was treated  with respect”, “I think that  everyone in the hospital is  treated equally”, “health  staff always used my   IADH: “I don’t think that  everyone receive same  treatment in the hospital,  my child was not treated  with respect”  (parent/carers);   Ensure that children of  minority and other  status are not  discriminated and have  equal access to health  services;   Guarantee competent  page 45 preferred name”  (adolescent 12‐18 years old,  parent/carer);   BCDH: “Health care workers  spoke on different  languages, so I didn’t need  an interpreter” (adolescent  18 years old);   JODH: “Hospital provided an  interpreter” (adolescent 12‐ 18 years old);   IKJRH: “The nurse has  translated me from Russian  to Kyrgyz language”  (adolescent 13 years old);   IADH: More comprehensive  examination of children is  required in kindergartens,  orphanages, and “risk  group” children (comment  from parent/carer);   TDH, BCDH, IKJRH, KBDH,  NCMCH, MDH, SDH, JODH:  “I (child) was given an  opportunity to be examined  by the doctor of the same  gender” (adolescent 12‐18  years old, parent/carers);   IKJRH, KBDH, IADH, NCMCH,  MDH, SDH, JODH: “I (child)  have an opportunity to stay  in double room in the  hospital” (adolescents 12‐18  years old, parent/carer);   BCDH, IKJRH, KBDH, NCMCH,  MDH, SDH, JODH: “I was  informed and examined in a  private area” (adolescents  12‐18 years old).   IADH: “Hospital didn’t  provide an interpreter,  medical staff didn’t call  my child by his name”  (parent/carers);   KBDH, IADH, NCMCH,  MDH, SDH: “Hospital  didn’t provide an  interpreter” (adolescents  12‐18 years old,  parent/carers);   TDH, BCDH: “I didn’t have  an option to stay in single  or double rooms in the  hospital” (adolescent 15,  18 years old);   TDH, IADH: “I (child) was  not informed in private  area, but examined in a  private area” (adolescent  15 years old, child  parent/carer);   TOH, IADH: “My child  didn’t have a choice be  examined by the doctor  of the same gender”  (child parent/carer);   NCMCH: “I didn’t have a  choice be examined by  the doctor of the same  gender” (adolescent 12‐ 18 years old);   TOH, IADH, KBDH: “We  didn’t have an option to  stay in single or double  rooms in the hospital”  (child parent/carer);   TOH: “Child was not  informed in a private area  and I didn’t know  whether he was  examined privately” (6‐11  interpreters;   Ensure the right of  children to be  hospitalised in single or  double rooms, upon  request;   Ensure that children  have choice to be  examined by the  doctor of the same  gender;   Ensure the right of  children to be informed  and examined in  private areas.                      page 46 years old child parent);   KBDH, IADH, NCMCH:  “Child was not informed  and examined in a private  area” (parents/carers).  Annex 7. Kyrgyzstan – Standard 3: Play and Learning: inputs from the self-evaluation teams Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   The hospital policy  guarantees the right to  play for children (JODH,  BCDH, IKJRH, KBDH,  IADH, MDH, NCMCH,  SDH);   Designated and properly  equipped play rooms for  children (IKJRH, IADH,  NCMCH),    Play Specialists or  properly trained staff to  assist children during  play available (NCMCH);    There is a regular  practice to encourage  and help to play for  children (IKJRH – IMCI  game‐play skills);    Health care providers  use distraction  technique during  procedures and  treatment (JODH, IKJRH  – IMCI  recommendations,  NCMCH);   Health care providers  were trained on how to  use different forms of  play within therapeutic  care (IKJRH – IMCI   The hospital policy  partly or not guarantees  the right to play for  children (TDH, TOH,  BADH),    No designated and  properly equipped play  rooms for children (TDH  – only space, BCDH –  only in paediatric  department, TOH,  KBDH, MDH, BADH,  SDH, JODH – lack of  toys);   No Play Specialists or  properly trained staff to  assist children during  play available (TDH,  JODH – partly due to  lack of staff, BCDH,  IKJRH, TOH, KBDH,  IADH, MDH, BADH,  SDH);   There is no regular  practice to encourage  and help to play for  children (TDH, JODH –  nurses play with  children, BCDH, TOH –  no toys, KBDH, IADH,  MDH, BADH, NCMCH,  SDH);   Health care providers   Develop a hospital policy to  guarantee the right to play for  children (TDH, TOH, BADH);   Designate and properly equip  (toys, games, music, etc.) the  play rooms for children (TDH,  BCDH, TOH, JODH, KBDH, MDH,  BADH, SDH);    Assign a Play Specialists or  properly trained staff to assist  children during play (TDH, JODH,  BCDH, IKJRH, TOH, KBDH, IADH,  MDH, BADH, SDH);   Develop a hospital strategy  involving play during procedures  and treatment (TDH, BCDH,  TOH, KBDH, IADH, MDH, BADH,  SDH);   Counsel with children and  parents/carers for the  improvement of play spaces  (TDH, BCDH, TOH, KBDH, IADH,  MDH, BADH, SDH);   Organize a hospital‐based school  (TDH, JODH, BCDH, IKJRH, TOH,  KBDH, IADH, MDH, NCMCH,  SDH);   Organize a supportive activities  such as clown, music, art, pet‐ therapy for children in the  hospital (TDH, BCDH, IKJRH,  page 47 recommendations,  NCMCH);    Opinion of  parents/carers and  children have been  gathered for the  improvement of play  spaces (JODH, IKJRH,  NCMCH);   Counselling with  children for the  improvement of play  spaces (IKJRH, NCMCH);    Hospital‐based school  activities (BADH);    Supportive activities  such as clown, music,  art, except pet‐therapy  are provided for  children in the hospital  (JODH, NCMCH)     were not trained on  how to use different  forms of play within  therapeutic care (TDH,  JODH, BCDH, TOH – no  resources to buy toys,  KBDH, IADH, MDH,  BADH, SDH);   There is no hospital  strategy involving play  during procedures and  treatment (TDH, BCDH,  TOH – no toys, KBDH,  IADH, MDH, BADH,  SDH);   No counselling with  children for the  improvement of play  spaces (TDH, BCDH,  TOH, KBDH, IADH, MDH,  BADH, SDH);   No hospital‐based  school (TDH, JODH,  BCDH, IKJRH, TOH,  KBDH, IADH, MDH,  NCMCH, SDH);   No supportive activities  such as clown, music,  art, pet‐therapy are  provided for children in  the hospital (TDH,  BCDH, IKJRH, TOH,  KBDH, IADH, MDH,  BADH, SDH)    TOH, KBDH, IADH, MDH, BADH,  SDH).  page 48 Annex 8. Kyrgyzstan – Standard 3: Play and Learning: Children’s and parents/carers’ views and evaluation Examples of Good  Practices  Areas that need improvement  Examples of actions for  improvement   TOH, KBDH, IADH: “I  played with my  mother” (6‐11 years  old);   BCDH, IKJRH, KBDH,  NCMCH, SDH, JODH: “I  had an opportunity to  play with girls and  boys in the hospital”  (children 6‐11 years  old, adolescent 12‐18  years old);   IKJRH: “I had an  opportunity to play  with girls in the ward”  (children 9 years old);   Health care workers  used a type of play  during procedures and  treatment”  (adolescent 12‐18  years old,  parents/carers);   NCMCH: “Child was  offered to continue  school work”  (parent/carer);   BCDH, KBDH, IADH: “I  was able to continue  my school work in the  hospital” (adolescent  12‐18 years old);   NCMCH: “I had an  opportunity of going  to school in the  hospital and I liked it”  (child 6‐11 years old);   TOH, TDH, BCDH, MDH: “I didn’t  have an opportunity to play in  the hospital” (6‐11 years old,  adolescent 12‐18 years old);   BCDH: “I didn’t have an  opportunity to play in the  hospital because I had to be in  the bed. My mother was singing  a song for me” (child 7 years old);  BCDH, IKJRH, KBDH, IADH, MDH,  SDH, JODH: “I didn’t have an  opportunity of going to school in  the hospital” (all children 6‐11  years old, parents/carers);   IADH: “I played with myself”  (child 6‐11 years old)   NCMCH: “There was a play room  and I had a chance to play in the  hospital. However, games there  were not for my age”;   BCDH, SDH, JODH: “There was no  play room or separate space to  play and nobody asked me what I  think about the play in the  hospital” (adolescents 12‐18  years old);   BCDH: “There is no computer  room or sport space in the  hospital” (adolescent 18 years  old);   TOH, IKJRH, NCMCH: “I didn’t  have an opportunity of going to  school in the hospital” (children  6‐11 years old);   TDH, KBDH, MDH, TOH, IADH,  SDH: all children didn’t have an   Organize a play room and  leisure hours for children  in the hospital;   Equip and supply a play  room with toys and  games;   Organize a separate  space for play and rest of  adolescents (computers,  chess, etc.)   Organize a hospital‐ based school;   Organize games in the  hospital relevant for the  age of  children/adolescents;   Train staff on play‐game  skills in paediatric  hospitals.  page 49  IKJRH: “The doctor  was always joking and  telling the verses  during examination,  treatment and  procedures”  (adolescent 12‐18  years old);    opportunity to play, and didn’t  have an opportunity of going to  school in the hospital (children,  parents/carers);   TOH: “I wasn’t able to keep up  with school work from here, I  didn’t like it” (6‐11 years old);   NCMCH: “I have undertaken a  self school work in the hospital”  (adolescent 12‐18 years old);   NCMCH:”There were no activities  like clown, music, art in the  hospital” (parents/carers);   TOH: “I didn’t have an  opportunity to play in the  hospital since there were no  toys” (6‐11 years old);   TOH: “Nobody in the hospital  who I could play with” (6‐11  years old);   IKJRH: “There was no play room  in the hospital, I watched TV in  the hall” (adolescent 12‐18 years  old);   TOH: “There is no school in the  hospital”;   TOH: “There is no designated  play rooms for children in the  hospital” (parent of child 6‐11  years old);   TOH: “No supportive activities  such as clown, music, art, pet‐ therapy are provided for children  in the hospital” (parent of child  6‐11 years old);   IADH: “My child didn’t have an  opportunity to play, there was no  designated play rooms for  children or trained staff in the  hospital” (parent/carer).  page 50 Annex 9. Kyrgyzstan –Standard 4: Information and participation: inputs from the self-evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   Children are informed  about their right to  express their views  freely (JODH, IKJRH,  IADH, BADH, NCMCH,  SDH);   Health care staff  introduce themselves to  children and families  and wear name badges  (TDH, JODH, BCDH,  IKJRH, MDH, NCMCH),    There is a policy  outlining the criteria for  children’s informed  consent to treatment  (JODH, IKJRH, KBDH,  IADH, MDH, BADH,  NCMCH, SDH);   The hospital ensures  explanation to  parents/carers and  children about the  medical situation (JODH,  BCDH, IKJRH, IADH,  MDH, BADH, NCMCH,  SDH);    There is engagement of  children for the  development and  improvement of health  care services through  their periodic  questioning, children  receive feedback about  the outcomes of survey  (JODH, MDH, NCMCH);   Children’s participation  influences decision‐  There is no leaflets or other relevant  materials (or it is limited) available  on full, accessible, diversity‐sensitive  and age‐appropriate information  about children’s right to express  their view freely (TDH, BCDH, TOH,  KBDH, MDH);    Health care staff introduce  themselves to children and families  and wear name badges – partly  available (TOH, KBDH, IADH, BADH,  SDH);   The hospital partly ensures  explanation to parents/carers and  children about the medical situation  (TOH, KBDH);    There is no policy outlining the  criteria for children’s informed  consent to treatment (TDH, TOH);   Health care providers have not been  trained on how to effectively  communicate with children and  families to explain the condition,  proposed treatments, etc. (TDH);   There is no engagement of children  for the development and  improvement of health care services  (TDH, BCDH, TOH, KBDH);   There is partial engagement of  children for the development and  improvement of health care services,  without provision of feedback about  the outcomes of survey (SDH);   There is engagement of children for  the development and improvement  of health care services, without or  with partial provision of feedback   Ensure awareness  raising and  continuous training  for staff on the  importance of  communicating  with patients of all  ages and ways to  do this (knowledge‐ skills);   Engage  children/parents/ca rers for the  development and  improvement of  health care services  and provide  feedback about the  outcomes of patent  satisfaction survey;   Ensure children’s  participation  influences the  decision‐making in  relation to  improvement of  hospital health care  services.  page 51 making in relation to  improvement of health  care services (JODH,  BADH, NCMCH, SDH).  about the outcomes of survey  (IKJRH, TOH, KBDH, IADH, BADH);   Children’s participation partly or  don’t influences decision‐making in  relation to improvement of health  care services (TDH, BCDH, IKJRH,  TOH, KBDH, IADH, MDH).  Annex 10. Kyrgyzstan – Standard 4: Information and participation: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   TOH, BCDH, IKJRH, KBDH,  NCMCH, MDH, SDH, JODH:  “Doctor explained to me why I  am sick. I understood what he  said. I was given information  about my sickness and the  treatment” (6‐11 years old – 10  children; adolescent 12‐18  years old, parents/carers);   TOH, IKJRH, KBDH, SDH, JODH:  “We received enough  information about the medical  condition of the child and we  were informed about possibility  to ask questions” (adolescent  12‐18 years old, parent of child  6‐11 years old);   TDH, BCDH, IKJRH, KBDH, IADH,  NCMCH: “I was given verbal  recommendations about  keeping myself healthy and the  information was useful”  (adolescents 12‐18 years old,  parents/carers);   TDH, BCDH, IKJRH, KBDH,  NCMCH, MDH, SDH, JODH: “I  was informed that I could ask  health professional questions,  and tell medical workers how I  was feeling, my thoughts and  opinions have been listened to”  (adolescents 12‐18 years old,   TOH, IADH: “Nobody  informed my child about the  right to express views freely  and I didn’t know whether  anybody asked his consent  to treatment”  (parents/carers of child 6‐11  years old);   TDH: “Nobody told me why I  came to the hospital” (child 7  years old);   IADH: “Doctor didn’t explain  me why I got sick” (child 6‐11  years old);   IADH: “I don’t think that we  have received enough  information from health care  workers about the medical  condition of child and I was  not informed about  possibility to ask questions”  (parent/carer);   TDH: “I didn’t understand  what doctor said” (child 7  years old);   TDH: “I don’t know who to  talk if I am unhappy in the  hospital” (child 7 years old);   BCDH: “I talked with my   Ensure that all  children are  informed about the  medical condition  and have the right  to give consent to  treatment and ask  questions;   Ensure that all  health care staff  introduces  themselves to  children and  parents/carers and  wear a name badge. page 52 parents/carers);   TDH: “I understood everything  that was said by health staff”  (adolescent 15 years old);   BCDH, IKJRH, KBDH, NCMCH,  MDH, SDH, JODH: “Health care  workers introduced themselves  and had name badges”  (adolescents 12‐18 years old,  parents/carers);   BCDH, IKJRH, KBDH, NCMCH,  MDH, JODH: “I was informed  about possibility to give  informed consent to treatment  and I’ve given consent for  treatment” (adolescent 12‐18  years old, parents/carers).  grandmother if something  was making me unhappy in  the hospital” (child 7 years  old);   TDH: “I was not informed  about the right to express  my views” (adolescent 15  years old);   TDH: “I was not informed  about possibility to give  informed consent to  treatment” (adolescent 15  years old);   TDH, IADH, NCMCH: “Health  staff didn’t introduce  themselves and didn’t wear  a name badge” (adolescent  15 years old, parent/carer).  Annex 11. Kyrgyzstan –Standard 5: Safety and environment: inputs from the self-evaluation teams Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   The hospital infrastructure is  designed, furnished and equipped to  meet children’s safety and mobility  needs (JODH, BCDH, IKJRH, TOH,  KBDH, BADH, NCMCH);    The hospital infrastructure ensures  that children with mobility restrictions  are able to access all areas of the  hospital (JODH, IKJRH, IADH, BADH,  NCMCH);   The hospital ensures that equipment  and materials follow safety norms  (JODH, IKJRH, KBDH, IADH, BADH,  NCMCH);   Free food is provided to all  hospitalised children (TDH, JODH,  BCDH, IKJRH, TOH, KBDH, IADH, MDH,  BADH, NCMCH‐ children up to 5 years  old, SDH);   The hospital  infrastructure is  partly designed,  furnished and  equipped to meet  children’s safety and  mobility needs (TDH,  IADH, MDH, SDH);   The hospital  infrastructure is  partly or not ensures  that children with  mobility restrictions  are able to access all  areas of the hospital  (TDH, BCDH, TOH,  KBDH, MDH, SDH);   The hospital partly  ensures that  equipment and   Undertake actions  to improve the  hospital  infrastructure to  meet children’s  safety and mobility  needs, and children  with mobility  restrictions (TDH,  BCDH, TOH, KBDH,  MDH, SDH, IADH);   Ensure that  equipment and  materials follow  safety norms (TDH,  BCDH, TOH, MDH,  SDH);   Ensure that food is  provided to all  hospitalised  page 53  Food is given to children at  appropriate times (TDH, JODH, BCDH,  IKJRH, TOH, KBDH, IADH, MDH, BADH,  NCMCH, SDH);   Menu is prepared by nutrition  specialist (TDH, JODH, BCDH, IKJRH,  TOH, KBDH, IADH, BADH, NCMCH,  SDH);   Hospital practice ensures effective  cleaning services (TDH, JODH, BCDH,  IKJRH, TOH, KBDH, IADH, MDH, BADH,  NCMCH, SDH);   Hospital encourages health staff to  follow strict cleaning procedures  (TDH, JODH, BCDH, IKJRH, TOH, KBDH,  IADH, MDH, BADH, NCMCH, SDH).  materials follow  safety norms (TDH,  BCDH, TOH, MDH,  SDH);   Menu is not  prepared by  nutrition specialist  (MDH).  children and menu  is prepared by  nutrition specialist.    Annex 12. Kyrgyzstan – Standard 5: Safety and environment: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   BCDH, KBDH, IADH, NCMCH:  “If I have mobility restrictions  I would be able to move  around all areas of the  hospital easily” (adolescent  12‐18 years old,  parents/carers);   TOH, TDH, BCDH, BADH,  IKJRH, KBDH, IADH, NCMCH,  MDH, SDH, JODH: “I (child)  timely received free food in  the hospital and the food was  healthy and tasty” (6‐11 years  old child, adolescent 12‐18  years old, parents/carers);   TOH, TDH, BCDH, IKJRH,  KBDH, IADH, NCMCH, MDH,  SDH, JODH: “It is clean in the  hospital and medical workers  always cleaned hands” (6‐11  years old child, adolescent    TDH, MDH, SDH, JODH: “If I  have mobility restrictions I  wouldn’t be able to move  around all areas of the  hospital easily or I don’t  know” (adolescents 12‐18  years old);   BCDH: “The hospital should  have a modern equipment  not to go far away for tests  like MRT and other  examinations” (adolescent  18 years old);     Undertake actions to  improve the hospital  infrastructure to meet  children’s safety and  mobility needs, and  children with mobility  restrictions.    page 54 12‐18 years old,  parents/carers);   rights” (adolescent 12‐18  years old, parents/carers).  Annex 13. Kyrgyzstan – Standard 6: Protection: inputs from the self- evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   The policy on protection of  children who have been  victims of any kind of abuse or  violence is in place (JODH,  BCDH, IKJRH, TOH, KBDH,  IADH, MDH, BADH, NCMCH);   The child‐protective referral  mechanisms with social  services, police, other  authorities in place (TDH,  JODH, BCDH, IKJRH, KBDH,  IADH, MDH, BADH, NCMCH,  SDH);   There is a unit within the  hospital dealing with child‐ protection issues (JODH, IKJRH,  NCMCH, SDH);   There is a system to register  and monitor cases of children  who have been a victim of any  kind of abuse (JODH, BCDH,  IKJRH, KBDH, IADH, BADH,  NCMCH, SDH);   Health professionals were  trained on how to identify and  examine children who have  been abused, and on existing  protocols and referral  mechanisms based on  handbook (JODH, IKJRH, KBDH  (partly trained), BADH,  NCMCH, SDH);   The regular assessment of   The policy on protection of  children who have been  victims of any kind of abuse  or violence is partly in place  (TDH, SDH);   The child‐protective referral  mechanisms with social  services, police, other  authorities is not in place  (TOH – no registered cases);   There is no team or unit  within the hospital dealing  with child‐protection issues  (TDH, BCDH, TOH, KBDH,  IADH, MDH, BADH);    There is no system to register  and monitor cases of children  who have been a victim of  any kind of abuse (TDH, TOH,  MDH);    Health professionals were  not trained on how to  identify and examine children  who have been abused, and  on existing protocols and  referral mechanisms (TDH,  BCDH, TOH – no registered  cases, IADH, MDH);    The services assessment to  ensure effectiveness in  protecting children is not  regular or not implemented  (TDH, TOH – no registered   Develop and  endorse the policy  on protection of  children who have  been victims of any  kind of abuse or  violence (TDH, SDH);   Organize and  implement a  continuous  awareness  raising/training  courses for staff on  how to identify and  examine children  who have been  abused, and on  existing protocols  (all hospitals);   Formally endorse an  effective referral  mechanisms;   Assign the team or  unit within the  hospital dealing with  child‐protection  issues (TDH, BCDH,  TOH, KBDH, IADH,  MDH, BADH);    Ensure regular  assessment of  effectiveness in  protecting children  of any kind of abuse  page 55 services ensures effectiveness  in protecting children (JODH,  BCDH, IKJRH, MDH, BADH,  NCMCH, SDH);   No clinical research or  experimentation project have  been carried out (TDH, JODH,  BCDH, SDH);   Specific protocols regulating  clinical research and trials  (IKJRH, KBDH, MDH, BADH,  NCMCH, SDH);   Hospital has Ethics Committee  for clinical research and trials  (BADH, NCMCH, SDH);   Hospital promotes monitoring  and evaluation to ensure that  the standards are observed  (BADH, NCMCH, SDH);   Children and families have the  option to refuse or not to be  involved in teaching activities  of the hospital (TDH, JODH,  BCDH, KBDH, IADH, BADH,  NCMCH, SDH);   Without informed consent the  research is not performed  (JODH, BCDH, KBDH, MDH,  BADH, NCMCH, SDH).  cases, KBDH, IADH);   The clinical research and  trials are not regulated by  hospital policy: no specific  protocols regulating clinical  research and trials (TDH,  JODH, BCDH, TOH, IADH);    No Ethics Committee for  clinical research and trials  (TDH, JODH, BCDH, IKJRH,  TOH, KBDH, IADH, MDH);    No practice of informed  consent for research (IKJRH,  TOH, IADH);    Children and families partly  have the option to refuse or  not to be involved in teaching  activities of the hospital  (IKJRH, TOH, MDH).  in the hospital (TDH,  TOH, KBDH, IADH);   Ensure that no  clinical research and  trials in carried out  without adequate  regulations;   Ensure that no child  participates in  clinical research or  trials without having  given their informed  consent;   Ensure that every  child has the option  to refuse or not to  be involved in the  teaching activities of  the hospital and that  they are aware of it.  Annex 14. Kyrgyzstan –Standard 6: Protection: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   TOH, TDH, BCDH, IKJRH,  KBDH, BADH, JODH, IADH,  NCMCH, MDH, SDH:    All children, adolescents  and parents/carers  responded that they felt  safe in the hospital.    KBDH: One parent/carer  responded that he/she  didn’t know whether it  was safe or not in the  hospital.   IADH: “It should be special  service for counselling with  psychologists in case of any  kind of abuse of child”  (comment from parent/carer)    page 56 Annex 15. Kyrgyzstan – Standard 7: Pain management and palliative care: inputs from the self-evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   The protocols and  procedures for  prevention and  management pain is  developed (KBDH, MDH,  NCMCH, SDH);   Special Pain Research  Unit or equivalent in the  hospital (IKJRH, MDH,  SDH);   There is continuous  training for staff on pain  management (IKJRH,  MDH, SDH);   The hospital promotes  an audits to assess pain  management services  (IKJRH, MDH, SDH);   Palliative care begins  when the illness is  diagnosed, and  continues (TDH, JODH,  IKJRH, MDH, NCMCH,  SDH);   Palliative care includes  psychological support to  the child’s family  (parents/carers and  carers) (TDH, JODH,  IKJRH, IADH, MDH,  NCMCH, SDH);   The hospital has  partnerships in place to  provide palliative care on  the community services  or at home (TDH, JODH,  IKJRH, NCMCH, SDH).   The protocols and procedures  for prevention and  management pain are partly  or not developed (TDH, JODH  – only in admission and  resuscitation departments,  BCDH, IKJRH – only in  paediatric resuscitation  department, TOH, IADH,  BADH);    No special Pain Research Unit  or equivalent in the hospital  (TDH, JODH – only in  admission and resuscitation  departments, BCDH, TOH,  KBDH, IADH, BADH, NCMCH‐  partly);   The hospital partly promotes  or does not have audits to  assess pain management  services (TDH, JODH, BCDH,  TOH, KBDH, IADH, BADH);    There is no continuous training  for staff on pain management  (TDH, JODH – only in  admission and resuscitation  departments, BCDH, TOH,  KBDH, IADH, BADH, NCMCH –  partly);   Palliative care partly begins  when the illness is diagnosed,  and continues (BCDH, TOH,  KBDH, IADH);    No palliative care begins when  the illness is diagnosed, and  continues (BADH);    Palliative care partly includes  or doesn’t include   Develop, endorse and  introduce the national  protocols on palliative  care, procedures for  prevention and  management of pain;   Introduce an initial and  continuous follow‐up  training for health care  staff in the area of pain  management;   Set up a Unit for  Psychological/ Psychiatry  Support within hospitals  for hospitalised children  and their families, as well  as to any other  child/adolescent in the  community;   Build partnerships to  provide palliative care on  the community services  or at home.    page 57 psychological support to the  child’s family (parents/carers  and carers) (BCDH, TOH,  KBDH, BADH);    The hospital has NO  partnerships in place or partly  in place to provide palliative  care on the community  services or at home (BCDH,  TOH, KBDH, IADH, MDH,  BADH).  Annex 16. Kyrgyzstan – Standard 7: Pain management and palliative care: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need  improvement  Examples of actions for  improvement   TOH, NCMCH: “I didn’t feel pain in  the hospital” (6‐11 years old);   TDH: “I felt pain in the hospital  (child 7 years old);   TOH, BCDH, KBDH, BCDH, IADH,  NCMCH, MDH, SDH, JODH: “I (child)  felt pain in the hospital and doctors,  nurses and parents/carers asked me  whether I feel pain, and they helped  me to ease the pain “ (6‐11 years  old) – 6 children, adolescents 12‐18  years old, and parents/carers);   BCDH, NCMCH: “I (child) was given  medicine for pain relief, and  psychological support to make me  feel more comfortable” (adolescent  18 years old, parent‐carer);   BCDH: “Health care workers asked  me about whether I feel pain”  (adolescent 18 years old);   TDH: “I felt pain in the hospital and  doctors helped me to ease the  pain” (2 children 7 years old);   TDH: “Health professionals asked   TOH: “Nobody  asked me about  whether I felt  pain” (6‐11 years  old);   TDH, MDH, JODH:  “I was given  medicine for pain  relief, but nothing  else to make me  feel more  comfortable”  (adolescents 12‐18  years old);   IADH: “Child was  given medicine for  pain relief, but  nothing else to  make him feel  more comfortable,  no psychological  support”  (parent/carer).     Set up a Unit for  Psychological/ Psychiatry  Support within hospitals  for hospitalised children  and their families, as well  as to any other  child/adolescent in the  community.  page 58 me if I have pain” (adolescent 15  years old);   IKJRH, NCMCH: I didn’t feel pain in  the hospital, but the nurse and  doctor always asked me whether I  feel pain” (children 7 years old – 2,  adolescent 11‐18 years old);  Annex 17. Tajikistan – Standard 1: Quality Services for Children: inputs from the self-evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   Health care service delivered  to children is based on  national and international  guidelines (CDHF, CDHH,  KTRH, CDHR, CDHJ, CDHK,  CDHVo, CDHY, CDHP,  CDHVa);   Doctors who work with  children are graduates of  paediatric faculty (CDHF)   Doctors who work with  children were trained in  paediatric care (CDHH, KTRH,  CDHR (almost all), CDHJ,  CDHK, CDHVo, CDHP);   Nurses have a paediatric  education (CDHVo);    Hospital facilitate in carrying  out of audit to meet health  care services in line with the  organizational policy and  action plan (CDHF – annually,  CDHH, KTRH, CDHR, CDHJ,  CDHK, CDHVo, CDHY, CDHP,  CDHVa);   Patient satisfaction surveys  are carried out and effective  system of patient satisfaction  surveys is implemented  (CDHR, CDHJ, CDHVo, CDHP,   Not all doctors who work  with children were trained  in paediatric care (CDHY,  CDHVa);   Nurses don’t have or partly  have a paediatric education  (CDHF, CDHH, KTRH, CDHR,  CDHJ, CDHK, CDHY, CDHP,  CDHVa);   No patient satisfaction  surveys carried out or  partly carried out (CDHF,  CDHH, KTRH, CDHJ, CDHK,  CDHVo, CDHY, CDHVa);    No effective system of  patient satisfaction surveys  (CDHF, CDHH, KTRH, CDHJ,  CDHK, CDHY – only verbal  questioning of  parents/carers, CDHVa);   The hospital didn’t adopt a  Charter on Children’s Right  (CDHK, CDHVo, CDHVa);   Health care service staff  were not formally trained  about the Charter and  Children’s Right (CDHF,  CDHH, CDHJ, CDHK, CDHVo,  CDHY, CDHP, CDHVa);   Ensure that all doctors  and nurses are trained  in paediatrics    Where doctors and  nurses have no training  in paediatrics, provide  continuous training or  awareness raising on  specific aspects of  caring for children of  different ages and  conditions   Formally and fully adopt  a Charter on Children’s  Right;    Educate all health care  service staff (doctors  and nurses) on the  Charter and Children’s  Right;   Improve the process of  setting and introduction  of an effective system of  patient satisfaction  surveys;    Facilitate in carrying out  of audit to meet health  care services in line with  the organizational  policy;  page 59 CDHH);    The hospital adopted a  Charter on Children’s Right  (CDHF, CDHJ, CDHY, CDHP  (no display in the wards),    The hospital adopted the  own version of a Charter on  Children’s Right and train  health care service staff  (KTRH, CDHR);    Parents/carers are allowed to  stay with the child during  procedures (CDHF, CDHH,  KTRH, CDHR, CDHK, CDHVo,  CDHY, CDHP, CDHJ);   At least one parent/carer is  allowed to stay in the  hospital with the child  overnight for free (all  hospitals, CDHH, KTRH,  CDHR, CDHJ (but lack of  space), CDHK (children up to  4 years old), CDHVo, CDHP);   Parents/carers are allowed to  receive free or subsidized  meals at the hospital (CDHF‐  free lunch, CDHR, CDHVo –  one time, CDHVa – one  time);   There is adolescent‐friendly  health services in the  hospital (CDHR, CDHJ, CDHK,  CDHVo) and/or there is a  hospital‐based center for  anonymous visits of  adolescents, CDHP, CDHVa);;    There is adolescent‐friendly  health facility reaches out to  adolescents (CDHVa);   Parents/carers are not  allowed to stay with the  child during induction of  anaesthesia (CDHJ, CDHVa,  CDHP, CDHVo, CDHK);    Parents/carers are not  always allowed to stay with  the child during procedures  (CDHVa);   Parent/carer is not always  allowed to stay in the  hospital with the child  overnight for free (CDHF‐ lack of beds, CDHY – no  opportunities, CDHVa);   Only 1 daily meal is  provided by the hospital  (CDHJ, CDHVa, CDHP,  CDHVo, CDHK);   Parents/carers are not able  to receive free or  subsidized meals at the  hospital (CDHJ, CDHP,  CDHK, CDHH, KTRH, CDHY);   There is no adolescent‐ friendly health services in  the hospital (CDHF, CDHH,  KTRH; CDHY –    There is no adolescent‐ friendly health facility  reaches out to adolescents  (CDHF, CDHH, KTRH,  CDHR);      Ensure that  parents/carers are  always allowed to stay  with the child overnight  for free;   Ensure that  parents/carers are  allowed to receive free  or subsidized meals in  the hospital;   Allow  parents/carers’/carers`  presence during  induction of anaesthesia  in all desired cases, as  well as during  procedures;   Organize an adolescent‐ friendly health services  in the hospital and an  adolescent‐friendly  health facility reaches  out to adolescents;    page 60 Annex 18. Tajikistan – Standard 1: Quality Services for Children: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   All Hospitals: The question  presented to children for the  consideration of this right  was: “Do you believe you  received the best care  possible”. Childrens’  comments were as follows:   “I am sure I received the best  care” (16 years old);   “ I felt very well cared for  here” (14 years old);   “I liked how I was treated by  the hospital staff” (12 years  old);   “Yes, I received very good  care” (13 years old);   KTRH, CDHR, CDHK: The  question presented to  parents/carers for the  consideration of this right  was: “Do you believe that  your child received the best  care possible”. parents/carers  responded: “Yes”.   CDHR, CDHF, CDHVo, CDHP: “I  have seen the stand in the  department with the  information about children’s  rights” (adolescents 12‐18  years old, parents/carers);   KTRH, CDHJ, CDHR, CDHH,  CDHF, CDHY, CDHVa, CDHVo,  CDHP, CDHK: “I participated in  patient satisfaction survey for  improvement hospital health  care services”  (parents/carers, adolescent   The questions presented to  children in consideration of  this right were: “Did you  participate in survey on  evaluation and improvement  of medical services?”   CDHVo, CDHR, CDHVa, CDHP:  “I did not participate in any  surveys” (adolescent 12‐18  years old, parents/carers);   KTRH, CDHJ, CDHH, CDHF,  CDHY, CDHVa, CDHP, CDHK: “I  haven’t received the copy of  the Charter on Children’s  Right, I haven’t seen any  stands with written  information and nobody  talked with me about the  children’s rights” (adolescents  12‐18 years old,  parents/carers);   CDHVo: “I haven’t received  the copy of the Charter on  Children’s Right, I haven’t  seen any stands with written  information, but health care  staff talked with me about the  children’s rights” (adolescents  12‐18 years old);   CDHP, CDHK: “I haven’t  received the copy of the  Charter on Children’s Right,  but I have seen stands with  written information, and  health care staff talked with  me about the children’s  rights” (parent/carer);   KTRH: “I didn’t participate in  patient satisfaction survey,   Ensure that children  and parents/carers  participate in patient  satisfaction surveys;   Ensure that the  outcomes of patient  satisfaction survey  always  communicated back  to children and  parents/carers and  contribute to the  decision‐making.   Distribute the copy  of the Charter on  Children’s Right  among hospitalised  children and inform  them about their  rights.   Ensure that  parents/carers are  always allowed to  stay with the child  overnight for free;   Ensure that  parents/carers are  allowed to receive  free or subsidized  meals in the  hospital;   Allow  parents/carers’/care rs` presence during  induction of  anaesthesia in all  desired cases, as well  as during  procedures.  page 61 12‐18 years old);   KTRH, CDHJ, CDHR, CDHF,  CDHY, CDHVa, CDHVo, CDHP,  CDHK: “People I met in the  hospital were friendly, they  were attentive to my opinion,  I was happy with the services  provided, good nurse,  confidentiality was respected  in all aspects of treatment  and care (adolescents 12‐18  years old);   KTRH, CDHJ, CDHR, CDHF,  CDHY, CDHVa, CDHVo, CDHP,  CDHK: “Parents/carers stayed  with me in the ward, including  overnight. I feel comfortable  when my mother always with  me” (children 6‐11 years old,  adolescents 12‐18 years old);   CDHR, CDHF, CDHY, CDHP,  CDHK: “Relatives stayed with  me in the hospital including  presence during procedures  (adolescents 12‐18 years old);    CDHR, CDHF, CDHP, CDHK:  “My mother was with me  during operation” (adolescent  12‐18 years old);   CDHH, CDHF, CDHF, CDHVo,  CDHP, CDHK: “I was allowed  to stay with my child  overnight and during  anaesthesia or operation”  (parent/carer);   KTRH: “My parents/carers  didn’t stay with me in the  hospital because they work,  but nurse was taking care  about me” (child 6‐11 years  old);   KTRH, CDHJ, CDHR, CDHH,  CDHF, CDHY, CDHVa, CDHP: “I  there was no need”  (adolescents 12‐18 years old);   KTRH, CDHJ, CDHH, CDHF,  CDHY, CDHVa, CDHVo, CDHK:  “I didn’t participate in patient  satisfaction survey and  nobody asked my or child’s  opinion about health care  services in the hospital”  (parents/carers, adolescents  12‐18 years old);   CDHH: “People in the hospital  were friendly, but I didn’t like  the services provided,  confidentiality was not  respected in all aspects of  treatment and care”  (adolescent 12‐18 years old);   KTRH: “I wanted  parents/carers to stay with  me, but they didn’t stay with  me in the hospital since they  have to work” (adolescent 12‐ 18 years old);   KTRH: “Parents/carers didn’t  stay with me during  procedures, but I wanted  them to be with me”  (adolescent 12‐18 years old);   CDHH: “Parents/carers didn’t  stay with me during  procedures and overnight”  (children 6‐11 years old);   CDHJ, CDHVo:”I was not  provided free food during my  stay with my child in the  hospital” (parents/carers);   CDHH, CDHVo: “I didn’t want  my parents/carers to stay  with me and they didn’t stay  with me overnight, but they  stayed with me during  procedures and operation”   Ensure that all  children receiving  care have the same  rights and benefits.  page 62 was allowed to have my  mobile phone and laptop with  me” (adolescents 12‐18 years  old);   KTRH, CDHJ, CDHR:”I stayed  with my child during the  whole process of treatment,  including presence during  procedures, and was allowed  to stay overnight there  (parents/carers);   KTRH, CDHR:”I was provided  free food two times daily  whilst accompanying my  child” (parents/carers);   CDHVa, CDHP, CDHK: I was  provided free food one time  daily whilst accompanying my  child” (parents/carers).  (adolescent 12‐18 years old);   CDHVo: I was not allowed to  have my mobile phone and  laptop with me” (adolescents  12‐18 years old);   CDHK: “I don’t have mobile  phone and laptop since I don’t  have an opportunities”  (adolescents 12‐18 years old);   CDHF: “It was non‐caloric  food” (parents/carers);    Annex 19. Tajikistan – Standard 2: Equality and non-discrimination: inputs from the self-evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   There is a hospital policy to  ensure that children of  minority and other status are  not discriminated and have  equal access to health  services (CDHF, CDHH, KTRH,  CDHR, CDHJ, CDHK, CDHVo,  CDHY, CDHP, CDHVa);   Hospital staff is trained on  respect and care of patients  with cultural differences  (CDHF, CDHH, KTRH, CDHR,  CDHJ, CDHK, CDHVo, CDHY,  CDHP, CDHVa);   Hospital policy guarantees  culturally competent staff or  volunteers (CDHF, CDHH,  KTRH, CDHR, CDHK, CDHVo,  CDHP);    Hospital policy not always  guarantees culturally  competent staff or volunteers  (CDHVa);   Hospital does not provide  qualified interpreter (CDHJ,  CDHVo, CDHY, CDHP, CDHVa);  Children not always can be  hospitalised in single or  double rooms, upon request  (CDHF – wards for 3 children,  CDHH, KTRH, CDHJ, CDHVo,  CDHY, CDHP, CDHVa);   Children are not informed in  private areas (CDHF, CDHH,  KTRH, CDHJ, CDHK, CDHY,  CDHVa);   Develop or enhance  the program on  continuous cultural‐ competence training  for staff;   Guarantee  competent  interpreters,  culturally competent  staff or volunteers;   Ensure gender  balance among  health care staff that  children have choice  to be examined by  the doctor of the  same gender;   Ensure the right of  children to be  page 63  Most hospital employees are  fluent in Russian, Uzbek and  Tadjik (CDHVo, CDHJ, CDHVa,  CDHP, CDHK, CHDY, CDHF,  CDHY);   Hospital provides qualified  interpreter, if needed (CDHH,  KTRH, CDHR, CDHK);   Children have a choice to be  examined by the doctor of the  same gender (CDHK, CDHP,  CDHVo, CDHF, CDHH, CDHR,  CDHVa);   There are private areas for  informing and performing  examinations (CDHVo, CDHR,  CDHVo, CDHP);    There are private areas for  performing examinations  (CDHF, CDHH, KTRH, CDHK,  CDHY, CDHVa);   Private rooms are available  upon request (subject to  availability) (CDHVo);   Children can be hospitalised  in single or double rooms,  upon request (CDHR, CDHK).    Private areas for examination  are only available for initial  patient assessment, all  following assessments are  performed in patient rooms  (CDHJ);    No female doctors available in  the hospital (CDHJ, CDHY,  KTRH).  hospitalised in single  or double rooms,  upon request;    Ensure the right of  children to be  informed in private  areas;    Ensure the right of  children to be  examined in private  areas.    Annex 20. Tajikistan – Standard 2: Equality and non-discrimination: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   CDHVa: “I am Uzbek and I felt  that I was treated same as  everyone else here. Hospital  staff spoke Uzbek to me” (13  years old, parent/carer);   KTRH, CDHJ, CDHR, CDHH,  CDHF, CDHY, CDHVa, CDHVo,  CDHP, CDHK: “I (child) was   CDHH, CDHK: “An interpreter  was not offered, there was no  interpreter” (adolescent 12‐ 18 years old, parent/carer)   KTRH, CDHY: “No female  doctors available in the  hospital, all doctors are male”  (adolescent 12‐18 years old,   Guarantee  competent  interpreters;   Ensure the right of  children to be  hospitalised in single  or double rooms,  upon request;  page 64 treated with respect”, “I think  that everyone in the hospital  is treated equally”, “health  staff tenderly used my  preferred name”, “I liked the  way they treated me here”  (adolescents 12‐18 years old,  parent/carer);   KTRH, CDHJ, CDHF, CDHY,  CDHVo, CDHP, CDHK: “I (we)  didn’t need an interpreter”  (adolescent 12‐18 years old,  parent/carer);   KTRH, CDHJ: “My child was  treated with respect”, “I think  that everyone in the hospital  is treated equally”, “health  staff always used preferred  name of my child”  (parent/carer);   CDHR: “When I need the  hospital offered an  interpreter” (adolescent 12‐ 18 years old,  parents/carers/carer).   KTRH: “We had male doctor,  so my child was given an  opportunity to be examined  by the doctor of the same  gender (parent/carers);   CDHR, CDHF, CDHVo, CDHP,  CDHK: “Yes, I (my child) had  an opportunity to be  examined by the doctor of the  same gender. In our hospital  you can be examined by the  doctor who you select”  (adolescent 12‐18 years old,  parent/carers);   CDHR, CDHY, CDHVa, CDHVo,  CDHK: “I (my child) have an  option to stay in single or  double rooms in the hospital”  (adolescent 12‐18 years old,  parent/carer);   CDHVa: “My father was with  me during examination” (girl  adolescent 12‐18 years old);   CDHVa: “My child was not  given an opportunity to be  examined by the doctor of the  same gender (parent/carers);   CDHJ, CDHH: “My child was  not given an opportunity to  be examined by the doctor of  the same gender since they  don’t have specialist of the  same gender” (parent/carers);  CDHJ, CDHP, CDHY, CDHVa: “I  was not given an opportunity  to be examined by the doctor  of the same gender, they  have lack of specialists”  (adolescent 12‐18 years old);   KTRH, CDHJ, CDHH, CDHF,  CDHVa, CDHP: “I (my child)  didn’t have an option to stay  in single or double rooms in  the hospital” (adolescent 12‐ 18 years old, parent/carers);   KTRH, CDHJ, CDHH, CDHF: “I  (child) was not informed in  private area, but examined in  a private area” (adolescent  12‐18 years old, child  parent/carer);   CDHH, CDHK: “I (child) was  not informed and examined in  private area” (adolescent 12‐ 18 years old, parent/carer);   CDHK: “I was informed in  admission department and  was examined not in a private  area (no rooms) (adolescent  12‐18 years old);   Ensure that children  have choice to be  examined by the  doctor of the same  gender;   Ensure the right of  children to be  informed and  examined in private  areas.  page 65 parent/carers);    KTRH, CDHR, CDHF, CDHY,  CDHVa, CDHVo, CDHP: “We  were informed and examined  in a private area”  (parent/carers, adolescents  12‐18 years old);   KTRH: “We received support  in accordance with our  religious faith”  (parent/carers).     CDHF: Comment from parent:  “I don’t understand why the  gender of a doctor plays role  in medicine? In my opinion  the most important that my  child was cured”  (parent/carer).  Annex 21. Tajikistan – Standard 3: Play and Learning: inputs from the self-evaluation teams Examples of Good  Practices  Areas that need improvement  Examples of actions for  improvement   The hospital policy  guarantees the right  to play for children  (CDHF, CDHR);    There is equipped  play room for  children (CDHR);    Health care providers  use distraction  technique during  procedures and  treatment (CDHVo).       The hospital policy doesn’t  guarantee the right to play for  children (CDHJ, CDHK, CDHY,  CDHP, CDHVa);   The hospital policy guarantees the  right to play for children, but  there is no resources to buy toys  (CDHH);    The hospital policy partly  guarantees the right to play for  children (KTRH, CDHVo);    No designated and properly  equipped play rooms for children  (CDHF, CDHH, KTRH, CDHJ, CDHK,  CDHVo, CDHY, CDHP, CDHVa);   No Play Specialists or properly  trained staff to assist children  during play available (CDHF,  CDHH, KTRH, CDHR, CDHJ, CDHK,  CDHVo, CDHY, CDHP, CDHVa);   Health care providers are not  trained or partly trained on  distraction technique during  procedures and treatment (KTRH,   Develop a hospital  policy to guarantee  the right to play for  children;   Designate and  properly equip (toys,  games, music, etc.)  the play rooms for  children;    Assign a Play  Specialists or  properly trained staff  to assist children  during play (all  hospitals);   Develop a hospital  strategy involving  play during  procedures and  treatment;   Counsel with children  and parents/carers  for the improvement  of play spaces (all  hospitals);   Organize a hospital‐ based school (all  page 66 CDHH, CDHF, CDHR, CDHJ, CDHJ,  CDHK, CDHVo, CDHY, CDHP,  CDHVa);   No hospital‐based school (CDHF,  CDHH, KTRH, CDHR, CDHJ, CDHK,  CDHVo, CDHY, CDHP, CDHVa).    hospitals);   Organize a supportive  activities such as  clown, music, art,  pet‐therapy for  children in the  hospital (all  hospitals).  Annex 22. Tajikistan – Standard 3: Play and Learning: Children’s and parents/carers’ views and evaluation Examples of Good  Practices  Areas that need improvement  Examples of actions for  improvement   CDHVo, CDHF, CDHY:  “I played with my  roommate in the  ward, mother helped  me” (children 6‐11  years old);   KTRH, CDHR, CDHVo:  “I (my child) had an  opportunity to play  with girls and boys in  the hospital”  (children 6‐11 years  old);   KTRH: “I was able to  continue my school  work in the hospital,  my school teacher  visited me in the  hospital” (adolescent  12‐18 years old);   CDHR: “Health care  staff helped me to  play, they asked my  opinion about  games, also they  played with me  during procedures  and treatment”  (adolescent 12‐18  years old,    CDHY, CDHH, CDHF, CDHY, CDHVa,  CDHVo, CDHP, CDHK: “I wasn’t  able to keep up with school work  from here because there is no  school and teacher” (child 6‐11  years old, adolescent 12‐18 years  old);   KTRH, CDHJ, CDHR, CDHF, CDHY,  CDHVa, CDHVo, CDHK: “I didn’t  have an opportunity of going to  school in the hospital because  there was no school, no  computers, it was not possible to  study. It would be good to have  teachers in the hospital” (all  children 6‐11 years old,  adolescents 12‐18 years old,  parents/carers);   CDHJ, CDHH, CDHP, CDHK: “I  didn’t play in the hospital, there  was nobody to play there” (child  6‐11 years old);   KTRH, CDHY, CDHVa: “I played  with my own toys. I played with  myself.” (child 6‐11 years old);   KTRH: “I had an opportunity to  play having my own toys, there  was a play room for children,  however the games in the hospital  were not relevant to my age,   Organize a play room and  leisure hours for children  in the hospital;   Equip and supply a play  room with toys and  games;   Organize a separate  space for play and rest of  adolescents (computers,  chess, etc.)   Organize a hospital‐ based school;   Organize games in the  hospital relevant for the  age of  children/adolescents;   Train staff on play‐game  skills in paediatric  hospitals.  page 67  CDHF, CDHVo:  “Health care  personnel uses  diversionary tactics  while making  examination and  procedures”  (parent/carer).  nobody asked my opinion about  games” (adolescent 12‐18 years  old);   KTRH, CDHJ, CDHF, CDHY, CDHVa,  CDHVo, CDHP, CDHK: “No place to  play, no people to help in the  hospital, nobody were interested  to find out our opinion. There are  no conditions for games, no toys,  no any entertainment activities,  we just stayed in the ward. No  specialist to help, just nurse who  was not trained in that aspect. It  would be good to have a play  room and toys for children in the  hospital” (parent/carer,  adolescent 12‐18 years old);   KTRH: “I have a little child, so we  didn’t ask about school”  (parent/carer);   CDHR, CDHH, CDHVa: “No play  room in the department, nobody  helped to play. It would be good  to have TV in the hospital”  (adolescent 12‐18 years old,  parent/carer);   CDHF: “No place to play, no play  room, no people to help in the  hospital. It would be good to have  a sports hall. No games in the  hospital relevant to my age,”  (adolescent 12‐18 years old).  Annex 23. Tajikistan – Standard 4: Information and Participation: inputs from the self-evaluation teams Examples of Good  Practices  Areas that need improvement  Examples of actions for  improvement   Children are  informed about  their right to express  their views freely  (CDHVo, CDHF,  KTRH, CDHR, CDHJ,  CDHP);   Health care providers have not  been trained on how to  effectively communicate with  children and families (CDHJ,  CDHP, CDHK, CDHVo, CDHY,  CDHVa);   Ensure awareness raising and  continuous training for staff  on the importance of  communicating with patients  of all ages and ways to do  this (knowledge‐skills);  page 68   Regular explanation  to parents/carers  and children about  the medical  situation (CDHVo,  CDHF, CDHH, KTRH,  CDHR, CDHY, CDHP);  The process by  which children and  adolescents can  voice concerns  about their health  care is implemented  (CDHF, CDHR, CDHJ,  CDHK, CDHVo, CDHY  – via parents/carers,  CDHP, CDHVa);   Children’s and  adolescents  complaints are  investigated, and  feedback is provided  (CDHR, CDHJ,  CDHVo, CDHP).                    Children are partly or not  informed about their right to  express their views freely  (CDHH, KTRH, CDHK, CDHY,  CDHVa);   The process by which children  and adolescents can voice  concerns about their health  care is not implemented  (CDHH, KTRH);    Children’s and adolescents  complaints are not formally  registered (CDHF – no  complaints, CDHH, CDHK – no  complaints, CDHY – no  complaints,   Children’s and adolescents  complaints are investigated,  but feedback is not provided  (KTRH, CDHVa).   Engage  children/parents/carers for  the development and  improvement of health care  services and provide  feedback about the  outcomes of patent  satisfaction survey;   Ensure children’s  participation influences the  decision‐making in relation  to improvement of hospital  health care services.   Ensure that every parent  receives information about  their child’s condition   Ensure that every child is  informed in a manner  appropriate to their evolving  capacities   Implement the process by  which children and  adolescents can voice  concerns about their health  care;   Set the process for  investigation and addressing  of the children’s and  adolescent’s complaints, and  mandatory informing them  about the outcomes of  investigation.  Annex 24. Tajikistan – Standard 4: Information and participation: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need improvement  Examples of actions  for improvement   CDHVo, KTRH, CDHR, CDHF,  CDHY, CDHVa, CDHP, CDHK:  “Doctor explained me why I got  sick. I understood what he said. I  believe I was given enough   KTRH, CDHR, CDHH, CDHF,  CDHY: “Nobody informed  me about the right to  express views freely, but I  could ask questions to   Ensure that  children are  properly informed  about the right to  express views  page 69 information about my sickness  and the treatment” (adolescents  12‐18 years old);   KTRH, CDHJ, CDHR, CDHH, CDHF,  CDHY, CDHVa, CDHVo, CDHP,  CDHK, CDHK: “Doctor explained  me and my mother why I got  sick. I understood what he said. I  was given information about my  disease and the treatment”  (children 6‐11 years old;  adolescent 12‐18 years old,  parents/carers);   KTRH: “Doctor explained my  parents/carers about my  disease, nurses explained to me  what to do to prevent sickness”  (child 6‐11 years old);   KTRH, CDHH, CDHF, CDHY,  CDHVa, CDHVo, CDHP: “Health  care specialists introduce  themselves and wear a name  badge” (adolescent 12‐18 years  old, parents/carers/carer);   KTRH, CDHJ, CDHH, CDHF, CDHY,  CDHVa, CDHVo, CDHP, CDHK: “I  was informed about possibility  to give informed consent to  treatment and I’ve given consent  for treatment” (adolescent 12‐18  years old, parents/carers);   KTRH: “I understood everything  that was said by health staff”  (adolescent 12‐18 years old);   KTRH, CDHJ, CDHR, CDHH,  CDHVa, CDHVo, CDHK: “I was  given verbal recommendations  about keeping good health of my  child and the information was  useful” (parents/carers,  adolescent 12‐18 years old);   KTRH, CDHJ, CDHR: “I was  informed about possibility to  health care staff”  (adolescent 12‐18 years old,  parents/carers);   CDHVo: “ I don’t know  whether my child was  informed about the right to  express views freely, but I  was informed that we can  ask questions”  (parent/carer);   CDHY, CDHVa: “I didn’t  understand everything what  doctor said to me about my  health status and treatment,  it was not enough  information” (adolescent 12‐ 18 years old);   CDHJ, CDHR, CDHH, CDHK:  “Health care specialists  introduce themselves, but  don’t wear a name badges”  (adolescent 12‐18 y.o);   CDHJ: “We haven’t been  informed about the right to  express views freely, nobody  wear a name badge”  (parent/carer);   CDHR: “I was informed  about possibility to give  informed consent to  treatment, but nobody  asked our consent for  treatment”  (parents/carers/carer of  child 6‐12 years old);   CDHF, CDHVa, CDHK: “I was  not informed about  possibility to give informed  consent to treatment, and  nobody asked our consent  for treatment” (adolescent  12‐18 years old,  parents/carers);  freely and about  medical condition;   Ensure that every  child is able to ask  questions and that  they understand  what is happening  to them;   Establish a hospital  policy on informed  consent;   Ensure that all  parents/carers or  children, where  applicable, always  give their consent  to treatment;   Ensure that all  health care staff  introduces  themselves to  children and  parents/carers and  wear a name  badge.   Ensure that  children and  adolescents always  know where they  can voice their  complaints and  further address the  problems.  page 70 give informed consent to  treatment and I’ve given consent  for treatment” (parents/carers,  adolescent 12‐18 years old);   KTRH, CDHJ, CDHR, CDHF: “We  (I) received enough information  about the medical condition of  the child and we (I) were  informed about possibility to ask  questions and rights”  (parents/carers, adolescents 12‐ 18 years old).   KTRH, CDHR, CDHP: “I know  where I can voice my  complaints” (children 6‐11 years  old, adolescents12‐18 years old);   KTRH, CDHJ, CDHF, CDHVa,  CDHVo, CDHK: “I know that I can  voice my complaints to my  parents/carers, doctor who treat  me and nurse, also head of the  department” (child 6‐11 years  old, adolescents12‐18 years old);   KTRH: “I know where I can voice  my complaints to the  department nurse” (adolescent  12‐18 years old)   CDHJ, CDHVa: “I can use the  book for complaints in the  hospital” (adolescent12‐18 years  old)   CDHF: “Health care staff  didn’t provide enough  information about sickness,  medical condition and  recommendations. Lack of  information about the  medical condition of my  child” (parents/carers).   The questions presented to  children in consideration of  this right were: “Did you  participate in a survey on  evaluation and  improvement of medical  services?”   CDHVo: “I did not  participate in any surveys”  (13 years old);   CDHR, CDHF, CDHP: “I don’t  feel comfortable to speak  about what I didn’t like in  the hospital, because they  cured me. I can speak with  my doctor” (child 6‐11 years  old);   CDHH, CDHY, CDHVo, CDHK:  “I don’t know where I can  voice my complaints”  (children 6‐11 years old,  adolescent 12‐18 years old).  Annex 25. Tajikistan – Standard 5: Safety and environment: Inputs from the self-evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   The hospital infrastructure is  designed, furnished and  equipped to meet children’s  safety and mobility needs  (CDHF, CDHH, KTRH, CDHR,  CDHY, CDHP);    The hospital infrastructure is  not designed, furnished and  equipped to meet children’s  safety and mobility needs  (CDHJ, CDHK, CDHVo,  CDHVa);   Allocate budget for  hospital renovation  and proper  functioning of  sewerage system, air  conditioning of the  hospital (CDHK,  page 71  The hospital infrastructure  ensures that children with  mobility restrictions are able to  access all areas of the hospital  (CDHR, CDHP);    The hospital ensures that  equipment and materials  follow safety norms (CDHH,  KTRH, CDHR, CDHJ, CDHVo,  CDHY, CDHP, CDHVa);   Free food is provided to all  hospitalised children (CDHF – 2  times, CDHH – but for  adolescents only 1 time meal,  KTRH – but for adolescents  only 1 time meal, CDHR,  CDHVo – only one time);    Food is given to children at  appropriate times (CDHF,  CDHH, KTRH, CDHR);    Menu is prepared by nutrition  specialist (CDHF, CDHR);   Hospital practice ensures  effective and cleaning services  (CDHF, CDHH, KTRH, CDHR,  CDHJ, CDHK, CDHVo, CDHY,  CDHP, CDHVa);   Hospital encourages health  staff to follow strict cleaning  procedures (CDHF, CDHH,  KTRH, CDHR, CDHJ, CDHVo,  CDHY, CDHP, CDHVa).     The hospital infrastructure  not ensures that children  with mobility restrictions are  able to access all areas of  the hospital (CDHF, CDHH,  KTRH, CDHJ, CDHK, CDHVo,  CDHY, CDHVa);   Food is given to children at  various time and menu is not  prepared by nutrition  specialist (CDHVo);    Free food is not provided or  partly provided to  hospitalised children (CDHJ,  CDHK, CDHY, CDHP, CDHVa);   The hospital partly or not  ensures that equipment and  materials follow safety  norms (CDHF, CDHK);    Hospital encourages health  staff to follow strict cleaning  procedures, but there is no  full functioning of sewerage  system in the hospital  (CDHK);    Menu is partly prepared by  nutrition specialist (CDHH,  KTRH);   Hospital menu is not  developed by a professional  nutritionist (CDHJ, CDHVa,  CDHP, CDHVo, CDHK, CDHF).  CDHJ, CDHR, CDHK);   Undertake actions to  improve the hospital  infrastructure to  meet children’s  safety and mobility  needs, and children  with mobility  restrictions;   Ensure that  equipment and  materials follow  safety norms;   Ensure that food is  provided to all  hospitalised children  and menu is  prepared by nutrition  specialist.    Annex 26. Tajikistan – Standard 5: Safety and environment: Children’s and parents/carers’ views and evaluation Examples of Good  Practices  Areas that need improvement  Examples of actions for  improvement   KTRH, CDHH, CDHP,  CDHK: “If I have   CDHJ, CDHR, CDHF, CDHY, CDHVa,  CDHVo: “If my child (I) has any mobility   Undertake actions  to improve the  page 72 mobility  restrictions I would  be able to move  around all areas of  the hospital with  assistance of health  care staff”  (adolescent 12‐18  years old,  parents/carers);   KTRH, CDHF: “I  (child) timely  received free food  in the hospital two  times daily, but it  would be good to  have a variety of  menu” (adolescent  12‐18 years old,  parents/carers);   CDHR, CDHH,  CDHP: “I (child)  timely received free  healthy food in the  hospital”  (adolescent 12‐18  years old,  parent/carer);   KTRH, CDHJ, CDHR,  CDHF, CDHY,  CDHVa, CDHVo,  CDHP, CDHK: “It  was clean in the  hospital and  medical workers  always cleaned  hands”  (adolescents 12‐18  years old,  parents/carers).    restrictions I don’t know would he be  able to move around all areas of the  hospital. There are no special conditions  for children with mobility restrictions”  (parents/carers, adolescent 12‐18 years  old);   CDHVa: “It was only free lunch in the  hospital, food was not given timely and I  don’t know was it healthy or not. Better  to have a food diversity” (adolescent 12‐ 18 years old, parent/carer);   CDHJ: “Food is brought from home, no  meal in the hospital, there is no single  wards, no child furniture, no beds, no air  conditioning, no play rooms, no toys and  games in the hospital. Hospital is  required renovation” (adolescent 12‐18  years old);   CDHY: “Food is brought from home”  (adolescent 12‐18 years old);   CDHF: “There is lack of equipment. It  would be good if hospital has better  medical equipment, more modern. The  department requires renovation”  (adolescents 12‐18 years old);   CDHJ: “My child received not the best  care, but treatment was good”  (parent/carer);   CDHH, CDHF: “My child received not the  best care,” (parent/carer);    CDHH, CDHF: “The food was not healthy  and was not timely given, lack of  attention in the hospital for the issue”  (parent/carer);   CDHJ: “I was asked about care, but not  any written questioning like patient  satisfaction survey, my child didn’t  participate in any patient satisfaction  surveys” (parent/carer);   CDHH: “It was not clean in the hospital”  (adolescents 12‐18 years old,  hospital  infrastructure to  meet children’s  safety and mobility  needs, and children  with mobility  restrictions.  page 73 parent/carer);   CDHJ: “Food for children we are bringing  from home” (parent/carer);   CDHJ: “Good doctors and nurses, but  wards are small, all for 4 children, the  toilet is in the yard of the hospital, it is  required renovation of the paediatric  departments” (parent/carer);   CDHR, CDHK: “It is hot and stifling indoor  and conditions of the department is not  good” (parent/carer, adolescent 12‐18  years old);   CDHF: “Health care services and  assistance in the hospital should be  improved. We live in XXI century. So far  my opinion didn’t influence the hospital  health care services. I don’t see  outcomes. We didn’t participate in  formal patient satisfaction survey, I am  not happy with health care services”  (parent/carers);   CDHF: “Medical workers not always  cleaned hands, hospital requires  renovation, it is not clean”  (parent/carer);   CDHVo, CDHP, CDHK: “Food is provided  only once a day in various time”  (adolescent 12‐18 years old,  parent/carer);   CDHK: “I don’t like the hospital” (child 6‐ 11 years old).  Annex 27. Tajikistan – Standard 6: Protection: inputs from the self- evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   Hospital has introduced a policy  on the protection of children  who have been victims of any  kind of abuse or violence and  staff is aware of it (CDHVo,   The child‐protective  referral mechanisms with  social services, police,  other authorities in place,  but require revision   Develop and endorse  the policy on  protection of  children who have  been victims of any  page 74 CDHF, CDHH, KTRH, CDHR, CDHJ,  CDHK, CDHY, CDHP, CDHVa);   The child‐protective referral  mechanisms with social services,  police, other authorities in place  (CDHH, KTRH, CDHR, CDHJ,  CDHK, CDHVo, CDHY, CDHP);    There is a team or unit within  the hospital dealing with child‐ protection issues (CDHR, CDHK,  CDHY);    There is formal system to  register and monitor cases of  children who have been a victim  of any kind of abuse (CDHR,  CDHJ, CDHK, CDHVo, CDHY,  CDHVa);   The assessment of services  ensures effectiveness in  protecting children (CDHF, CDHK,  CDHY, CDHP);    Training on existing protocols  and referral mechanisms  available (CDHVo, CDHR, CDHK,  CDHP);   No clinical research or  experimentation project carried  out (all hospitals);   There is an Ethics Committee for  clinical research and trials  (CDHR, CDHJ).  (CDHF);    There is no team or unit  within the hospital dealing  with child‐protection  issues (CDHF, CDHH, KTRH,  CDHJ, CDHVo, CDHP,  CDHVa);   There is no formal system  to register and monitor  cases of children who have  been a victim of any kind  of abuse (CDHF, CDHH‐  video camera, KTRH –  video camera, CDHP);    Health professionals were  not formally trained on  how to identify and  examine children who have  been abused, and on  existing protocols and  referral mechanisms  (CDHF, CDHH, KTRH, CDHJ,  CDHY, CDHVa);   No child‐protective referral  mechanisms in place  (CDHVa);   No Ethics Committee for  clinical research and trials  (CDHF, CDHH, KTRH, CDHK,  CDHVo, CDHY, CDHP,  CDHVa).    kind of abuse or  violence;    Organize and  implement a  continuous  awareness  raising/training  courses for staff on  how to identify and  examine children  who have been  abused, and on  existing protocols (all  hospitals);   Formally endorse an  effective referral  mechanisms;   Assign the team or  unit within the  hospital dealing with  child‐protection  issues;    Ensure regular  assessment of  effectiveness in  protecting children  of any kind of abuse  in the hospital.  Annex 28. Tajikistan – Standard 6: Protection: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   All children, adolescents and  parents/carers responded  that they felt safe in the  hospital (all hospitals);    CDHJ: “Regarding safety I  should say that the toilet is  located in the yard of the  hospital” (adolescent 12‐18  years old);   Ensure safety and  protection of children  from any kind of  abuse.  page 75  KTRH: “I think that health  care staff was doing  everything to protect my  child (parent of child 6‐11  years old);   CDHJ: “My child was not  affected in the hospital, so I  think that it was safe in the  hospital” (parent/carer).    Annex 29. Standard 7: Pain management and palliative care: inputs from the self-evaluation teams Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   The protocols and  procedures for  prevention and  management pain are  developed (CDHF, CDHR,  CDHJ, CDHK, CDHVo,  CDHY, CDHP, CDHVa);   All health staff have  been trained on pain  care (CDHVo, CDHR,  CDHK, CDHY, CDHP);   There is continuous  training for staff on pain  care (CDHVo);   The hospital has an  audits to assess pain  management services  (CDHR, CDHK, CDHVo,  CDHY, CDHP);    Palliative care includes  psychological support to  the child’s family (CDHF,  CDHR, CDHK, CDHVo,  CDHY).   No protocols and procedures  for prevention and  management pain were  developed (CDHH, KTRH);   No special Pain Research  Unit or equivalent in the  hospital (all hospitals);   There is no continuous  training for staff on pain  management (CDHK, CDHJ,  CDHVa, CDHP, CDHY, CDHH,  CDHF, KTRH, CDHR);   The hospital doesn’t have an  audits to assess pain  management services (CDHF,  CDHH, KTRH, CDHJ, CDHVa);   No psychological support  available for patients and  families (CDHJ, CDHVa,  CDHP, CDHVo, CDHK, KTRH).   Develop, endorse and  introduce the national  protocols on palliative care,  procedures for prevention  and management of pain;   Introduce an initial and  continuous follow‐up  training for health care  staff in the area of pain  management;   Set up a Unit for  Psychological/ Psychiatry  Support within hospitals for  hospitalised children and  their families, as well as to  any other child/adolescent  in the community;   Build partnerships to  provide palliative care on  the community services or  at home.    page 76 Annex 30. Tajikistan – Standard 7: Pain management and palliative care: Children’s and parents/carers’ views and evaluation Examples of Good Practices  Areas that need improvement  Examples of actions for  improvement   KTRH, CDHH, CDHF, CDHVa, CDHP:  “I didn’t feel pain in the hospital,  but the nurse always asked me  whether I feel pain and helped  me” (children 6‐11 years old,  adolescent 12‐18 years old,  parent/carer);   KTRH, CDHJ, CDHR, CDHY, CDHVa,  CDHVo, CDHP, CDHK: “I (child) felt  pain in the hospital and doctors,  nurses and parents/carers asked  me whether I feel pain, and they  helped me to ease the pain” (child  6‐11 years old, adolescents 12‐18  years old, parents/carers);   KTRH: “Health staff was saying  kind and warm words, trying to  help my child, also asked every  hour how my child feels”  (parents/carers);   CDHJ, CDHR, CDHH, CDHP: “My  child was offered a psychological  support and we received care in  accordance with our religious  faith” (parent/cares);   CDHF, CDHK: “I can’t say about  psychological support since we  didn’t need it. It was supporting  conversations. We received care  in accordance with our religious  faith” (parent/cares).   KTRH, CDHVa: “I think that  there is no doctor‐ psychologist in the  hospital” (parents/carers);   CDHH: “I didn’t feel pain in  the hospital and nobody  asked me whether I feel  pain” (child 6‐11 years old);  CDHF: “My child felt pain  after injections, but  nobody did anything to  ease the pain except  friendly approach, when  sometimes medical  workers asked whether the  child feel pain”  (parent/carer of child 6‐11  years old);   CDHK: “Hospital has only  ibuprofen for treatment of  headache” (adolescent 12‐ 18 years old).   Set up a Unit for  Psychological/  Psychiatry Support  within hospitals for  hospitalised  children and their  families, as well as  to any other  child/adolescent in  the community.  The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Original: English ASSESSING THE RESPECT OF CHILDREN’S RIGHTS IN HOSPITALS IN KYRGYZSTAN AND TAJIKISTAN This report describes findings and recommendations of the assessment of children’s rights in hospital in Kyrgyzstan and Tajikistan that took place in the framework of a WHO project to support the improvement of quality of paediatric care funded by the Russian Federation. In the framework of the assessment of quality of paediatric care, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 11 hospitals in Kyrgyzstan and 10 hospitals in Tajikistan.. Assessing the respect of children’s rights in hospitals in Kyrgyzstan and Tajikistan WHO project: Improving the quality of paediatric care in the first level referral hospitals in selected countries of central Asia World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int