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Tarus A, Msemo G, Kamuyu R, Shamba D, Kirby RP, Palamountain KM, Gicheha E, Kumar MB, Powell-Jackson T, Bohne C, Murless-Collins S, Liaghati-Mobarhan S, Morgan A, Oden ZM, Richards-Kortum R, Lawn JE. Devices and furniture for small and sick newborn care: systematic development of a planning and costing tool. BMC Pediatr 2023; 23:566. [PMID: 37968613 PMCID: PMC10652422 DOI: 10.1186/s12887-023-04363-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 10/12/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND High-quality neonatal care requires sufficient functional medical devices, furniture, fixtures, and use by trained healthcare workers, however there is lack of publicly available tools for quantification and costing. This paper describes development and use of a planning and costing tool regarding furniture, fixtures and devices to support scale-up of WHO level-2 neonatal care, for national and global newborn survival targets. METHODS We followed a systematic process. First, we reviewed planning and costing tools of relevance. Second, we co-designed a new tool to estimate furniture and device set-up costs for a default 40-bed level-2 neonatal unit, incorporating input from multi-disciplinary experts and newborn care guidelines. Furniture and device lists were based off WHO guidelines/norms, UNICEF and national manuals/guides. Due to lack of evidence-based quantification, ratios were based on operational manuals, multi-country facility assessment data, and expert opinion. Default unit costs were from government procurement agency costs in Kenya, Nigeria, and Tanzania. Third, we refined the tool by national use in Tanzania. RESULTS The tool adapts activity-based costing (ABC) to estimate quantities and costs to equip a level-2 neonatal unit based on three components: (1) furniture/fixtures (18 default but editable items); (2) neonatal medical devices (16 product categories with minimum specifications for use in low-resource settings); (3) user training at device installation. The tool was used in Tanzania to generate procurement lists and cost estimates for level-2 scale-up in 171 hospitals (146 District and 25 Regional Referral). Total incremental cost of all new furniture and equipment acquisition, installation, and user training were US$93,000 per District hospital (level-2 care) and US$346,000 per Regional Referral hospital. Estimated cost per capita for whole-country district coverage was US$0.23, representing 0.57% increase in government health expenditure per capita and additional 0.35% for all Regional Referral hospitals. CONCLUSION Given 2.3 million neonatal deaths and potential impact of level-2 newborn care, rational and efficient planning of devices linked to systems change is foundational. In future iterations, we aim to include consumables, spare parts, and maintenance cost options. More rigorous implementation research data are crucial to formulating evidence-based ratios for devices numbers per baby. Use of this tool could help overcome gaps in devices numbers, advance efficiency and quality of neonatal care.
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Affiliation(s)
- Alice Tarus
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK.
| | - Georgina Msemo
- Global Financing Facility, the World Bank Group, Washington, DC, USA
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - Rosemary Kamuyu
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Donat Shamba
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar Es Salaam, Tanzania
| | - Rebecca P Kirby
- Kellogg School of Management, Northwestern University, Evanston, IL, USA
| | | | - Edith Gicheha
- Rice360 Institute for Global Health Technologies, Houston, TX, USA
| | - Meghan Bruce Kumar
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Kenya Medical Research Institute- Wellcome Trust Research Program, Nairobi, Kenya
| | - Timothy Powell-Jackson
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Christine Bohne
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar Es Salaam, Tanzania
- Rice360 Institute for Global Health Technologies, Houston, TX, USA
| | - Sarah Murless-Collins
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Alison Morgan
- Global Financing Facility, the World Bank Group, Washington, DC, USA
| | - Z Maria Oden
- Rice360 Institute for Global Health Technologies, Houston, TX, USA
| | | | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
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Lakin K, Kane S. What can one legitimately expect from a health system? A conceptual analysis and a proposal for research and action. BMJ Glob Health 2023; 8:e012453. [PMID: 37400118 DOI: 10.1136/bmjgh-2023-012453] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/10/2023] [Indexed: 07/05/2023] Open
Abstract
In 2007, the WHO proposed the Building Blocks Framework and articulated 'responsiveness' as one of the four goals for health systems. While researchers have studied and measured health systems responsiveness since, several aspects of the concept remain unexamined, including, understanding the notion of 'legitimate expectations'-a notion central to the definition of responsiveness. We begin this analysis by providing a conceptual overview of how 'legitimacy' is understood in key social science disciplines. Drawing on insights from this overview, we examine how 'legitimacy' is understood in the literature on health systems responsiveness and reveal that there is currently little critical engagement with this notion of the 'legitimacy' of expectations. In response, we unpack the concept of 'legitimate' expectations and propose approaches and areas for reflection, research, and action. We conclude that contestation, and ongoing negotiation of entrenched health system processes and norms which establish citizens' 'legitimate' expectations of health systems, is needed-through processes that ensure equitable and wide participation. We also call on researchers, in their capacity as key health policy actors, to trigger and initiate processes and help create equitable spaces for citizens to participate in establishing 'legitimate' expectations of health systems.
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Affiliation(s)
- Kimberly Lakin
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Oluoch D, Hinton L, English M, Irimu G, Onyango T, Jones COH. Mothers' involvement in providing care for their hospitalised sick newborns in Kenya: a focused ethnographic account. BMC Pregnancy Childbirth 2023; 23:389. [PMID: 37237328 DOI: 10.1186/s12884-023-05686-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION There is growing evidence that parental participation in the care of small and sick newborns benefits both babies and parents. While studies have investigated the roles that mothers play in newborn units in high income contexts (HIC), there is little exploration of how contextual factors interplay to influence the ways in which mothers participate in the care of their small and sick newborn babies in very resource constrained settings such as those found in many countries in sub-Saharan Africa. METHODS Ethnographic methods (observations, informal conversations and formal interviews) were used to collect data during 627 h of fieldwork between March 2017 and August 2018 in the neonatal units of one government and one faith-based hospital in Kenya. Data were analysed using a modified grounded theory approach. RESULTS There were marked differences between the hospitals in the participation by mothers in the care of their sick newborn babies. The timing and types of caring task that the mothers undertook were shaped by the structural, economic and social context of the hospitals. In the resource constrained government funded hospital, the immediate informal and unplanned delegation of care to mothers was routine. In the faith-based hospital mothers were initially separated from their babies and introduced to bathing and diaper change tasks slowly under the close supervision of nurses. In both hospitals appropriate breast-feeding support was lacking, and the needs of the mothers were largely ignored. CONCLUSION In highly resource constrained hospitals with low nurse to baby ratios, mothers are required to provide primary and some specialised care to their sick newborns with little information or support on how undertake the necessary tasks. In better resourced hospital settings, most caring tasks are initially performed by nurses leaving mothers feeling powerless and worried about their capacity to care for their babies after discharge. Interventions need to focus on how to better equip hospitals and nurses to support mothers in caring for their sick newborns, promoting family centred care.
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Affiliation(s)
- Dorothy Oluoch
- Centre for Geographic Medicine (Coast), KEMRI-Wellcome Trust research programme, Nairobi, Kenya.
| | - Lisa Hinton
- THIS Institute, University of Cambridge, Cambridge, UK
| | - Mike English
- Centre for Geographic Medicine (Coast), KEMRI-Wellcome Trust research programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, NUFFIELD department of medicine, University of Oxford, Oxford, UK
| | - Grace Irimu
- Centre for Geographic Medicine (Coast), KEMRI-Wellcome Trust research programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Truphena Onyango
- Centre for Geographic Medicine (Coast), KEMRI-Wellcome Trust research programme, Nairobi, Kenya
| | - Caroline O H Jones
- Centre for Geographic Medicine (Coast), KEMRI-Wellcome Trust research programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, NUFFIELD department of medicine, University of Oxford, Oxford, UK
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Wanyama C, Blacklock C, Jepkosgei J, English M, Hinton L, McKnight J, Molyneux S, Boga M, Musitia PM, Wong G. Protocol for the Pathways Study: a realist evaluation of staff social ties and communication in the delivery of neonatal care in Kenya. BMJ Open 2023; 13:e066150. [PMID: 36914188 PMCID: PMC10016238 DOI: 10.1136/bmjopen-2022-066150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 02/22/2023] [Indexed: 03/14/2023] Open
Abstract
INTRODUCTION The informal social ties that health workers form with their colleagues influence knowledge, skills and individual and group behaviours and norms in the workplace. However, improved understanding of these 'software' aspects of the workforce (eg, relationships, norms, power) have been neglected in health systems research. In Kenya, neonatal mortality has lagged despite reductions in other age groups under 5 years. A rich understanding of workforce social ties is likely to be valuable to inform behavioural change initiatives seeking to improve quality of neonatal healthcare.This study aims to better understand the relational components among health workers in Kenyan neonatal care areas, and how such understanding might inform the design and implementation of quality improvement interventions targeting health workers' behaviours. METHODS AND ANALYSIS We will collect data in two phases. In phase 1, we will conduct non-participant observation of hospital staff during patient care and hospital meetings, a social network questionnaire with staff, in-depth interviews, key informant interviews and focus group discussions at two large public hospitals in Kenya. Data will be collected purposively and analysed using realist evaluation, interim analyses including thematic analysis of qualitative data and quantitative analysis of social network metrics. In phase 2, a stakeholder workshop will be held to discuss and refine phase one findings.Study findings will help refine an evolving programme theory with recommendations used to develop theory-informed interventions targeted at enhancing quality improvement efforts in Kenyan hospitals. ETHICS AND DISSEMINATION The study has been approved by Kenya Medical Research Institute (KEMRI/SERU/CGMR-C/241/4374) and Oxford Tropical Research Ethics Committee (OxTREC 519-22). Research findings will be shared with the sites, and disseminated in seminars, conferences and published in open-access scientific journals.
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Affiliation(s)
- Conrad Wanyama
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Claire Blacklock
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Juliet Jepkosgei
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine and Department of Paediatrics, Univerity of Oxford Nuffield Department of Medicine, Oxford, UK
| | - Lisa Hinton
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, UK
| | - Jacob McKnight
- Tropical Medicine, University of Oxford Nuffield Department of Medicine, Oxford, UK
- University of Oxford Nuffield Department of Clinical Medicine, Oxford, UK
| | - Sassy Molyneux
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Centre for Geographic Medicine Research-Coast, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mwanamvua Boga
- Centre for Geographic Medicine Research-Coast, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Peris Muoga Musitia
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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Ogola M, Wainaina J, Muinga N, Kimani W, Muriithi M, Aluvaala J, English M, Irimu G. Development of a small and sick newborn clinical audit tool and its implementation guide using a human-centred design approach newborn clinical audit process and design. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001577. [PMID: 36963070 PMCID: PMC10021839 DOI: 10.1371/journal.pgph.0001577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023]
Abstract
Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the clinical audit process must use a structured tool that comprehensively covers the continuum of newborn care from immediately after birth to the period of newborn unit care. The objective of the study was to co-design a newborn clinical audit tool that considered the key principles of a Human Centred Design approach. A three-step Human Centred Design approach was used that began by (1) understanding the context, the users and the available audit tools through literature, focus group discussions and a consensus meeting that was used to develop a prototype audit tool and its implementation guide, (2) the prototype audit tool was taken through several cycles of reviewing with users on real cases in a high volume newborn unit and refining it based on their feedback, and (3) the final prototype tool and the implementation guide were then tested in two high volume newborn units to determine their usability. Several cycles of evaluation and redesigning of the prototype audit tool revealed that the users preferred a comprehensive tool that catered to human factors such as reduced free text for ease of filling, length of the tool, and aesthetics. Identified facilitators and barriers influencing the newborn clinical audit in Kenyan public hospitals informed the design of an implementation guide that builds on the strengths and overcomes the barriers. We adopted a Human Centred Design approach to developing a newborn clinical audit tool and an implementation guide that we believe are comprehensive and consider the characteristics of the context of use and the user requirements.
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Affiliation(s)
- Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Pumwani Maternity Hospital, Nairobi, Kenya
| | - John Wainaina
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Naomi Muinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Ouma PO, Malla L, Wachira BW, Kiarie H, Mumo J, Snow RW, English M, Okiro EA. Geospatial mapping of timely access to inpatient neonatal care and its relationship to neonatal mortality in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000216. [PMID: 36962323 PMCID: PMC10021833 DOI: 10.1371/journal.pgph.0000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 05/27/2022] [Indexed: 11/18/2022]
Abstract
Globally, 2.4 million newborns die in the first month of life, with neonatal mortality rates (NMR) per 1,000 livebirths being highest in sub-Saharan Africa. Improving access to inpatient newborn care is necessary for reduction of neonatal deaths in the region. We explore the relationship between distance to inpatient hospital newborn care and neonatal mortality in Kenya. Data on service availability from numerous sources were used to map hospitals that care for newborns with very low birth weight (VLBW). Estimates of livebirths needing VLBW services were mapped from population census data at 100 m spatial resolution using a random forest algorithm and adjustments using a systematic review of livebirths needing these services. A cost distance algorithm that adjusted for proximity to roads, road speeds, land use and protected areas was used to define geographic access to hospitals offering VLBW services. County-level access metrics were then regressed against estimates of NMR to assess the contribution of geographic access to VLBW services on newborn deaths while controlling for wealth, maternal education and health workforce. 228 VLBW hospitals were mapped, with 29,729 births predicted as requiring VLBW services in 2019. Approximately 80.3% of these births were within 2 hours of the nearest VLBW hospital. Geographic access to these hospitals, ranged from less than 30% in Wajir and Turkana to as high as 80% in six counties. Regression analysis showed that a one percent increase in population within 2 hours of a VLBW hospital was associated with a reduction of NMR by 0.24. Despite access in the country being above the 80% threshold, 17/47 counties do not achieve this benchmark. To reduce inequities in NMR in Kenya, policies to improve care must reduce geographic barriers to access and progressively improve facilities' capacity to provide quality care for VLBW newborns.
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Affiliation(s)
- Paul O. Ouma
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Hellen Kiarie
- Health Sector Monitoring and Evaluation Unit, Ministry of Health, Nairobi, Kenya
| | - Jeremiah Mumo
- Health Sector Monitoring and Evaluation Unit, Ministry of Health, Nairobi, Kenya
| | - Robert W. Snow
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Roder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Glob Health 2021; 5:bmjgh-2020-002539. [PMID: 33055093 PMCID: PMC7559116 DOI: 10.1136/bmjgh-2020-002539] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/04/2020] [Accepted: 08/19/2020] [Indexed: 01/21/2023] Open
Abstract
Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.
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Affiliation(s)
| | - Kojo Nimako
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Nana A Y Twum-Danso
- Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Archana Amatya
- Health and Nutrition, Save the Children, Kathmandu, Nepal
| | - Ana Langer
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Margaret Kruk
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Irimu G, Aluvaala J, Malla L, Omoke S, Ogero M, Mbevi G, Waiyego M, Mwangi C, Were F, Gathara D, Agweyu A, Akech S, English M. Neonatal mortality in Kenyan hospitals: a multisite, retrospective, cohort study. BMJ Glob Health 2021; 6:e004475. [PMID: 34059493 PMCID: PMC8169483 DOI: 10.1136/bmjgh-2020-004475] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Most of the deaths among neonates in low-income and middle-income countries (LMICs) can be prevented through universal access to basic high-quality health services including essential facility-based inpatient care. However, poor routine data undermines data-informed efforts to monitor and promote improvements in the quality of newborn care across hospitals. METHODS Continuously collected routine patients' data from structured paper record forms for all admissions to newborn units (NBUs) from 16 purposively selected Kenyan public hospitals that are part of a clinical information network were analysed together with data from all paediatric admissions ages 0-13 years from 14 of these hospitals. Data are used to show the proportion of all admissions and deaths in the neonatal age group and examine morbidity and mortality patterns, stratified by birth weight, and their variation across hospitals. FINDINGS During the 354 hospital months study period, 90 222 patients were admitted to the 14 hospitals contributing NBU and general paediatric ward data. 46% of all the admissions were neonates (aged 0-28 days), but they accounted for 66% of the deaths in the age group 0-13 years. 41 657 inborn neonates were admitted in the NBUs across the 16 hospitals during the study period. 4266/41 657 died giving a crude mortality rate of 10.2% (95% CI 9.97% to 10.55%), with 60% of these deaths occurring on the first-day of admission. Intrapartum-related complications was the single most common diagnosis among the neonates with birth weight of 2000 g or more who died. A threefold variation in mortality across hospitals was observed for birth weight categories 1000-1499 g and 1500-1999 g. INTERPRETATION The high proportion of neonatal deaths in hospitals may reflect changing patterns of childhood mortality. Majority of newborns died of preventable causes (>95%). Despite availability of high-impact low-cost interventions, hospitals have high and very variable mortality proportions after stratification by birth weight.
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Affiliation(s)
- Grace Irimu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Jalemba Aluvaala
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Sylvia Omoke
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - George Mbevi
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mary Waiyego
- Health Services, Nairobi Metropolitan Services, Nairobi, Kenya
| | - Caroline Mwangi
- Division of Neonatal and Child Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Fred Were
- Kenya Paediatric Research Consortium (KEPRECON), Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Ambrose Agweyu
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI - Wellcome Trust Research Institute, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Oxford, Oxfordshire, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/24/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 01/25/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Gathara D, Zosi M, Serem G, Nzinga J, Murphy GAV, Jackson D, Brownie S, English M. Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement. HUMAN RESOURCES FOR HEALTH 2020; 18:34. [PMID: 32410633 PMCID: PMC7222310 DOI: 10.1186/s12960-020-00470-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning.
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Affiliation(s)
- David Gathara
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya.
- School of Nursing and Midwifery, Aga Khan University, P.O Box 39340 00623, Nairobi, Kenya.
| | - Mathias Zosi
- Kenya Medical Training College, Kilifi Campus, Nairobi, Kenya
| | - George Serem
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
| | - Jacinta Nzinga
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
| | | | - Debra Jackson
- School of Nursing & Midwifery, University of Technology, Sydney, Australia
| | - Sharon Brownie
- PRAXIS Forum, Green Templeton College, University of Oxford, Oxford, OX2 6HG, UK
- School of Medicine, Griffith University, Queensland, Australia
| | - Mike English
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
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Nyikuri M, Kumar P, Jones C, English M. "But you have to start somewhere….": Nurses' perceptions of what is required to provide quality neonatal care in selected hospitals, Kenya. Wellcome Open Res 2020; 4:195. [PMID: 32587896 PMCID: PMC7309418 DOI: 10.12688/wellcomeopenres.15592.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Kenya has one of the highest rates of neonatal mortality in the world at 22/1,000 live births. Improving the quality of newborn care would greatly improve survival rates. There is an increasing consensus that strong health systems are key to achieving improved health outcomes. However, there is significantly less agreement on what to strengthen in low and middle-income countries such as Kenya. As nurses are the main caregivers in many inpatient settings, efforts aimed at improving the quality of facility care for sick newborn babies need to take into account nurses views and opinions. Our intent in this paper is to describe the current state of the nursing environment and what would be required to improve the quality of those environs from nurses' perspectives. Methods: Between January 2017 and March 2018, we collected data through non-participant observations, unsolicited conversations and review of admission registers. We also conducted 29 individual in-depth interviews with nurses working in the newborn units (NBU) of a public sector hospital (n=10), a private sector hospital (n=11) and a faith-based hospital (n=8). The interviews were digitally audio recorded, transcribed verbatim and, together with observation notes, analysed using thematic content analysis. Results: Nurses as frontline care givers and intervention intermediaries, irrespective of their work contexts, have similar aspirations, needs and expectations from the health systems of how they should be supported to provide quality inpatient care for newborns. These are about the structure of the work environment, especially human resources for health, and the consequences of inadequate structure. They are also about how care is organised and systems that respond to emergencies. Conclusion: Interventions and investments to improve quality need to be directed towards experienced based co-design where we listen to the problems that nurses experience.
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Affiliation(s)
- Mary Nyikuri
- Strathmore University Business School, Strathmore University, P.O. Box 59857 – 00200, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Program, P.O. Box 43640 – 00100, Nairobi, Kenya
| | - Pratap Kumar
- Strathmore University Business School, Strathmore University, P.O. Box 59857 – 00200, Nairobi, Kenya
| | - Caroline Jones
- KEMRI-Wellcome Trust Research Program, P.O. Box 43640 – 00100, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Michael English
- KEMRI-Wellcome Trust Research Program, P.O. Box 43640 – 00100, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK
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English M, Gathara D, Nzinga J, Kumar P, Were F, Warfa O, Tallam-Kimaiyo E, Nandili M, Obengo A, Abuya N, Jackson D, Brownie S, Molyneux S, Jones COH, Murphy GAV, McKnight J. Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya. BMJ Glob Health 2020; 5:e001937. [PMID: 32133169 PMCID: PMC7042598 DOI: 10.1136/bmjgh-2019-001937] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 11/02/2022] Open
Abstract
There are global calls for research to support health system strengthening in low-income and middle-income countries (LMICs). To examine the nature and magnitude of gaps in access and quality of inpatient neonatal care provided to a largely poor urban population, we combined multiple epidemiological and health services methodologies. Conducting this work and generating findings was made possible through extensive formal and informal stakeholder engagement linked to flexibility in the research approach while keeping overall goals in mind. We learnt that 45% of sick newborns requiring hospital care in Nairobi probably do not access a suitable facility and that public hospitals provide 70% of care accessed with private sector care either poor quality or very expensive. Direct observations of care and ethnographic work show that critical nursing workforce shortages prevent delivery of high-quality care in high volume, low-cost facilities and likely threaten patient safety and nurses' well-being. In these challenging settings, routines and norms have evolved as collective coping strategies so health professionals maintain some sense of achievement in the face of impossible demands. Thus, the health system sustains a functional veneer that belies the stresses undermining quality, compassionate care. No one intervention will dramatically reduce neonatal mortality in this urban setting. In the short term, a substantial increase in the number of health workers, especially nurses, is required. This must be combined with longer term investment to address coverage gaps through redesign of services around functional tiers with improved information systems that support effective governance of public, private and not-for-profit sectors.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI – Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, Oxford, Oxfordshire, UK
| | - David Gathara
- Health Services Unit, KEMRI – Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacinta Nzinga
- Health Services Unit, KEMRI – Wellcome Trust Research Programme, Nairobi, Kenya
| | - Pratap Kumar
- Institute of Healthcare Management, Strathmore University Strathmore Business School, Nairobi, Nairobi Area, Kenya
- Health-E-Net Limited, Nairobi, Kenya
| | - Fred Were
- Department of Paediatrics, University of Nairobi, Nairobi, Nairobi, Kenya
| | - Osman Warfa
- Neonatal, Child and Adolescent Health Unit, Kenya Ministry of Health, Nairobi, Kenya
| | | | - Mary Nandili
- Neonatal, Child and Adolescent Health Unit, Kenya Ministry of Health, Nairobi, Kenya
| | - Alfred Obengo
- National Nurses Association of Kenya, Nairobi, Kenya
| | | | - Debra Jackson
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Sharon Brownie
- Griffith University Menzies Health Institute Queensland, Nathan, Queensland, Australia
| | - Sassy Molyneux
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, Oxford, UK
| | - Caroline Olivia Holmes Jones
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
- Department of Health System and Research Ethics, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Jacob McKnight
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
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Nyikuri M, Kumar P, Jones C, English M. "But you have to start somewhere….": Nurses' perceptions of what is required to provide quality neonatal care in selected hospitals, Kenya. Wellcome Open Res 2019; 4:195. [PMID: 32587896 PMCID: PMC7309418 DOI: 10.12688/wellcomeopenres.15592.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2019] [Indexed: 11/04/2023] Open
Abstract
Background: Kenya has one of the highest rates of neonatal mortality in the world at 22/1,000 live births. Improving the quality of newborn care would greatly improve survival rates. There is an increasing consensus that strong health systems are key to achieving improved health outcomes. However, there is significantly less agreement on what to strengthen in low and middle-income countries such as Kenya. As nurses are the main caregivers in many inpatient settings, efforts aimed at improving the quality of facility care for sick newborn babies need to take into account nurses views and opinions. Our intent in this paper is to describe the current state of the nursing environment and what would be required to improve the quality of those environs from nurses' perspectives. Methods: Between January 2017 and March 2018, we collected data through non-participant observations, unsolicited conversations and review of admission registers. We also conducted 29 individual in-depth interviews with nurses working in the newborn units (NBU) of a public sector hospital (n=10), a private sector hospital (n=11) and a faith-based hospital (n=8). The interviews were digitally audio recorded, transcribed verbatim and, together with observation notes, analysed using thematic content analysis. Results: Nurses as frontline care givers and intervention intermediaries, irrespective of their work contexts, have similar aspirations, needs and expectations from the health systems of how they should be supported to provide quality inpatient care for newborns. These are about the structure of the work environment, especially human resources for health, and the consequences of inadequate structure. They are also about how care is organised and systems that respond to emergencies. Conclusion: Interventions and investments to improve quality need to be directed towards experienced based co-design where we listen to the problems that nurses experience.
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Affiliation(s)
- Mary Nyikuri
- Strathmore University Business School, Strathmore University, P.O. Box 59857 – 00200, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Program, P.O. Box 43640 – 00100, Nairobi, Kenya
| | - Pratap Kumar
- Strathmore University Business School, Strathmore University, P.O. Box 59857 – 00200, Nairobi, Kenya
| | - Caroline Jones
- KEMRI-Wellcome Trust Research Program, P.O. Box 43640 – 00100, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Michael English
- KEMRI-Wellcome Trust Research Program, P.O. Box 43640 – 00100, Nairobi, Kenya
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK
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Tsiachristas A, Gathara D, Aluvaala J, Chege T, Barasa E, English M. Effective coverage and budget implications of skill-mix change to improve neonatal nursing care: an explorative simulation study in Kenya. BMJ Glob Health 2019; 4:e001817. [PMID: 31908859 PMCID: PMC6936475 DOI: 10.1136/bmjgh-2019-001817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/31/2019] [Accepted: 11/10/2019] [Indexed: 11/14/2022] Open
Abstract
Introduction Neonatal mortality is an urgent policy priority to improve global population health and reduce health inequality. As health systems in Kenya and elsewhere seek to tackle increased neonatal mortality by improving the quality of care, one option is to train and employ neonatal healthcare assistants (NHCAs) to support professional nurses by taking up low-skill tasks. Methods Monte-Carlo simulation was performed to estimate the potential impact of introducing NHCAs in neonatal nursing care in four public hospitals in Nairobi on effectively treated newborns and staff costs over a period of 10 years. The simulation was informed by data from 3 workshops with >10 stakeholders each, hospital records and scientific literature. Two univariate sensitivity analyses were performed to further address uncertainty. Results Stakeholders perceived that 49% of a nurse full-time equivalent could be safely delegated to NHCAs in standard care, 31% in intermediate care and 20% in intensive care. A skill-mix with nurses and NHCAs would require ~2.6 billionKenyan Shillings (KES) (US$26 million) to provide quality care to 58% of all newborns in need (ie, current level of coverage in Nairobi) over a period of 10 years. This skill-mix configuration would require ~6 billion KES (US$61 million) to provide quality of care to almost all newborns in need over 10 years. Conclusion Changing skill-mix in hospital care by introducing NHCAs may be an affordable way to reduce neonatal mortality in low/middle-income countries. This option should be considered in ongoing policy discussions and supported by further evidence.
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Affiliation(s)
| | - David Gathara
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Timothy Chege
- Institute of Healthcare management, Strathmore University, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, Centre for Geographic Medicine Research Coast, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Applegate JA, Ahmed S, Khan MA, Alam S, Kabir N, Islam M, Bhuiyan M, Islam J, Rashid I, Wall S, de Graft-Johnson J, Baqui AH, George J. Early implementation of guidelines for managing young infants with possible serious bacterial infection in Bangladesh. BMJ Glob Health 2019; 4:e001643. [PMID: 31803507 PMCID: PMC6882554 DOI: 10.1136/bmjgh-2019-001643] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 01/29/2023] Open
Abstract
Neonatal infections remain a leading cause of newborn deaths globally. In 2015, WHO issued guidelines for managing possible serious bacterial infection (PSBI) in young infants (0-59 days) with simpler antibiotic regimens if hospital referral is not feasible. Bangladesh was one of the first countries to adapt WHO guidance into national guidelines for implementation in primary healthcare facilities. Early implementation was led by the Ministry of Health and Family Welfare (MOHFW) in 10 subdistricts of Bangladesh with support from USAID's MaMoni Health System Strengthening project. This mixed methods implementation research case study explores programme feasibility and acceptability through analysis of service delivery data from 4590 sick young infants over a 15-month period, qualitative interviews with providers and MOHFW managers and documentation by project staff. Multistakeholder collaboration was key to ensuring facility readiness and feasibility of programme delivery. For the 514 (11%) infants classified as PSBI, provider adherence to prereferral treatment and follow-up varied across infection subcategories. Many clinical severe infection cases for whom referral was not feasible received the recommended two doses of injectable gentamicin and follow-up, suggesting delivery of simplified antibiotic treatment is feasible. However, prereferral antibiotic treatment was low for infants whose families accepted hospital referral, which highlights the need for additional focus on managing these cases in training and supervision. Systems for tracking sick infants that accept hospital referral are needed, and follow-up of all PSBI cases requires strengthening to ensure sick infants receive the recommended treatment, to monitor outcomes and assess the effectiveness of the programme. Only 11.2% (95% CI 10.3 to 12.1) of the expected PSBI cases sought care from the selected service delivery points in the programme period. However, increasing trends in utilisation suggest improved awareness and acceptability of services among families of young infants as the programme matured. Future programme activities should include interviews with caregivers to explore the complexities around referral feasibility and acceptability of simplified antibiotic treatment.
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Affiliation(s)
- Jennifer A Applegate
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sabbir Ahmed
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Marufa Aziz Khan
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Sanjida Alam
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Nazmul Kabir
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Munia Islam
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Mamun Bhuiyan
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
| | - Jahurul Islam
- National Newborn Health Program, Government of Bangladesh Ministry of Health and Family Welfare, Dhaka, Dhaka District, Bangladesh
| | - Iftekhar Rashid
- United States Agency for International Development, Dhaka, Bangladesh
| | - Steve Wall
- Save the Children, Washington, District of Columbia, USA
| | | | - Abdullah H Baqui
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Joby George
- MaMoni Health Systems Strengthening Project, Save the Children, Dhaka, Dhaka District, Bangladesh
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