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Basic hospital care may be key to saving newborn lives. Professor Mike English outlines a multidisciplinary project engaging policy-makers and practitioners in Kenya. This project demonstrated poor coverage of Nairobi’s 4.25 million population if a sick newborn baby needs quality hospital care. Using novel research approaches the team also identified how severe shortages of nurses contribute to poor quality of care for patients and negatively affect nurses themselves.

I’m Mike English, Professor of International Child Health with the Centre for Tropical Medicine and Global Health in Oxford, but I have lived and worked in Kenya at the Kemri-Wellcome Trust Research Programme.

The Health Services that Deliver for Newborns project was a set of multi-disciplinary work which we wrote a proposal for in 2013 and we’ve been working on this area for 4 years. The idea of the Health Service for Newborns project was to take Nairobi County as an example and understand how care for sick newborn babies - those that require to be admitted to hospital - how it is organised, what the capacity is, what are the challenges of delivering it is and what are some of the key quality issues.

Delivering high quality care is obviously a process that involves a huge number of different people from policy makers through to senior practitioners who lead and direct things through to those that actually provide the care, even the families themselves. We wanted to try and understand all of these elements and we were particularly concerned about, in some parts what capacity the system in Nairobi (which serves a population of 4.5 million people of whom a very large number are from very low income settings) has. We were particularly interested in what the capacity was to provide the right amounts of care.  We know that in Nairobi neonatal mortality, that’s the number of babies who die in the first month of life, is extremely high.

One of the major parts of this project was to try and understand the capacity to provide care for this Nairobi population. A lot of this work was led by a colleague of mine, Dr Georgina Murphy, working with a large set of Kenyan researchers. We had first to establish how much care is actually needed. We had to do that by using epidemiological approaches, by using lots of research findings that have estimated how many babies might get sick from particular conditions. We pulled together lots of this epidemiological research and made an estimate based on the number of births we know are happening in Nairobi County to suggest how many babies would need to access hospital services. That was one key piece of work.

Georgina and the team with David and others identified all the facilities that were expected to provide inpatient care for sick babies, that’s those babies that need to spend one or two or three or even sometimes many more nights in hospital receiving care. That was quite a bit of work to identify all of those, to reach out to them, to ask if they would be happy for us to engage them in the research and then actually using tools to go out and try and characterise fully what they’re capable of doing, the resources they have and some of their practices. It was about trying to assess the readiness of the system to offer care to the sick newborns that we know will be likely to be needing it.

The final thing we did was to check whether the medical care that was being provided was of a good standard. We used, as a standard, the national recommendations for how neonatal care should be provided. We had several sets of work all building up to help us understand that if you had a sick newborn in Nairobi, within 6 or 12 hours of birth, and that baby needs to be admitted into hospital, we were able to estimate how much care is available to them. Our estimates suggests that probably 40-45% of babies who should get to a good hospital for care probably never make it at all. Of the ones that do make it to the hospital we estimate that only half of those are actually admitted to a hospital that is ready to provide good quality care. So what that means in reality is that of all the babies that should get into a good hospital for care, only about one quarter actually make it into a place which can provide good quality care.

That was a whole set of work which is what we call effective coverage. One of our key results is that effective coverage is only available for 25% of babies who need hospital care in Nairobi County. Further work, and I think my colleagues are talking about this, went on to to investigate nursing care which wasn’t captured in this initial set of estimates. We now know from the nursing care work and evaluation, that even with the 25% that might access a place ready to provide good care, even if they reach those places, the challenges with nursing care are so profound that most babies probably don’t get high quality care.

Some of the key priorities we’ve identified in one sense may not be revolutionary but we’ve been able to provide information to underline their importance. Absolutely critical is that we need more nurses. The number of nurses available to provide care to these sick newborns is just too few, this is an absolutely critical need. We also found that the system of care for this population needs to be much better organised, and we probably need to think about different levels of care.

What we’ve seen is that the majority of people and particularly the poor people tend to use the government-provided services, and they’re completely overstretched. We need to strengthen the existing facilities but probably also think of ways in which we can add new facility-based care in smaller places, better distributed around the county so they can provide some basic forms of hospital care for newborns. If they are unable to provide more advanced care then we need systems were the babies and the mothers can be moved to a hospital were that care can be better provided.

There are actually quite major long term strategic issues for the health care system in Nairobi, and we think probably for the rest of the country, in how we are going to provide these services. There are issues of infrastructure. We need systems, we need to move people from one place to another should they need more advanced care, and then critically, the human resources we have able to offer that care.

This project has brought together epidemiologists, clinicians like myself as a paediatrician, social scientists, including anthropologists, statisticians; we’ve been working with policy makers, with senior professionals and with regulators. What it has shown us is that you need to make very special efforts to bring these groups together to help them understand each other. Each piece of work has its own methodology or approach, but it’s important that other parts of the team understand the value of those methods. It has also helped us to understand that these are long term processes and we’re learning as we go. It’s been very important to bring our stakeholders together on this journey because I think we’re in a better place now to continue doing further multi-disciplinary work going forwards to tackle many of the issues that we’ve now uncovered.

This interview was recorded in December 2018

Mike English

Mike English is a UK trained paediatrician who has worked in Kenya for over 20 years. His work often takes child and newborn health as a focus but increasingly tackles health services or wider health systems issues. He works as part of the KEMRI-Wellcome Trust Research Programme (KWTRP) in collaboration in Kenya with the Ministry of Health and a wide set of national and international collaborators. His work focuses predominantly on improving care in African District Hospitals.

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