Health Services that Deliver: Improving Care for Sick Newborns (HSD-N)

Lead Research Organisation: University of Oxford
Department Name: Tropical Medicine

Abstract

In 2009, there were 42,000 newborn deaths and they accounted for 40% of all deaths among children under 5 Kenya. This high neonatal mortality is a major reason why Kenya is not succeeding in its battle to reduce child deaths in line with stated targets. Recognising this, the Ministry of Health has started to focus on improving newborn (and maternal) health with strategies aimed at communities and small clinics. However, sick or vulnerable newborns will often require inpatient care in referral facilities from skilled workers with access to basic technologies. Interventions typically delivered at this level include, for example, fluids or feeds for those unable to suck or oxygen for respiratory support. Such interventions require carers to perform the same, time-consuming tasks multiple times per day for many days. Shortage of skilled health workers often means these services are inadequately delivered, potentially delaying or preventing recovery.
We are planning research that will establish: the potential burden of severe neonatal illness; what existing infrastructure and human resource capacity is available supporting access for this population; utilisation of these services; and the quality of existing nursing care services. We will do this focusing on Nairobi's population of 5 million, many of whom are very poor. With a focus on universal coverage and neonatal care meeting agreed standards, this work will provide the basis for estimating the gap between available and needed services (Gap 1) and the quality gap between existing and desired services (Gap 2). In partnership with important stakeholders, we will explore how a low-income country might best tackle health workforce challenges to close these gaps and improve provision of essential nursing care to all sick newborn babies in an affordable and efficient way. This ultimate aim of research is driven by the fact that salary costs are a major proportion of total health care costs. One option will therefore be to explore alternatives to employing professional nurses if necessary interventions can be effectively provided by other groups under the supervision of professionals - an approach known as task-shifting.
Although task-shifting sounds a simple solution, it may not always be. Failure to consider national regulations, the opinions of important professionals, managers or parents may lead to the approach being rejected or failing. Taking account of the local situation may be particularly important when those being cared for are sick, newborn babies and when day to day care has traditionally been given by professional, even specialist nurses.
First, therefore, we will define with the major groups what forms of care should be available to all, learn what regulations exist on providing care, and consider the concerns of major groups with respect to task-shifting. We will examine carefully all the things that nurses have to do in a range of different facilities, explore with experts which tasks may be simple enough for others to do, and examine whether there is time to do all the essential care tasks. We will estimate how much need there is for neonatal nursing care in Nairobi and the gap between what is available and what is needed. Using all these data we will explore how many new staff might be needed to improve the delivery of essential care for all newborns in need. We will also undertake preliminary work to explore the costs of meeting this need using extra professional nurses or if tasks were shifted to other, lower cost staff. Possible roles for lower cost staff will be informed by work examining what tasks to shift and how they might fit within existing patterns of providing care. All this work will be conducted with the major decision makers in health, health professionals and parents to develop options sensitive to local conditions. Based on this body of work we aim to develop a task-shifting approach that can be tested in Kenya in the future.

Technical Summary

A set of key health system challenges undermine newborn survival in low-income settings. These include limited access to quality care for sick newborns requiring inpatient services 24 hours a day throughout lengthy admissions and inadequate availability of appropriately skilled human resources. In three phases of work we will build on existing activities including formative ethnographic work to help understand nursing culture in hospitals and identify initial stakeholders and work to develop national neonatal guidelines to define core standards for care of sick newborns in hospitals. The second phase will begin with a formal stakeholder analysis and then comprise a set of distinct but inter-linked research activities using complementary approaches spanning different disciplines that address major thematic questions:
1. Epidemiology: What is the gap between capacity for providing an essential package of services for sick newborns and the likely magnitude of 'need' for this package (Gap 1)?
2. Ergonomics: What nursing time and skills are needed for effective delivery of interventions, are there gaps in the quantity or quality of tasks performed that place newborns at risk (Gap 2)?
3. Organisational science: How should context, including barriers, enablers and the cultures of facility based health worker teams guide possible task-shifting strategies?
4. Policy: Is task-shifting acceptable at regulatory, professional, team and user levels, in what forms and what are the implications for production and oversight of such service providers?
Throughout this phase of work stakeholders will be regularly engaged to discuss research designs and progress and to share their thinking on the implications for workforce planning and task-shifting, process itself studied in a form of action research. In the third phase we will use illustrative economic models to help identify workforce interventions to optimize coverage with high quality neonatal care with key stakeholders.

Planned Impact

The programme of work planned will have impact in a number of important areas:
Improving neonatal mortality and morbidity - It is estimated that between 1990 and 2009, 79 million neonatal deaths occurred worldwide. Over 98% of these occurred in low- and middle-income countries and in 2009 there were 42,000 neonatal deaths in Kenya alone. This work will inform future health system developments and reduce neonatal deaths by optimising coverage and quality of effective interventions and their efficient and equitable delivery at scale. This work will complement efforts to improve newborn care within communities or through primary care by improving services for sick or vulnerable newborns needing access to key interventions and basic technologies within facilities. For example, providing fluids or feeds for those unable to suck or oxygen for respiratory support. Effective delivery of such referral care will be central to continuing improvements in health status as non-communicable diseases, that include and may be attributable to preterm birth for example, become increasingly important contributors to burden of disease and costs.
Improving health system design and rational use of resources - Health care provision is often not strategically planned or informed by evidence in low-income settings but rather tends to follow the trajectory established in high-income settings where powerful professional voices and market mechanisms have often been at odds with considerations of efficiency and equity. This work seeks to inform medium and long term planning of critical services with important consequences for future health and costs. It will furthermore enhance policy makers' appreciation of evidence informed decisions linked to issues of affordability, efficiency and equity and prepare the ground for a major study of a complex intervention.
Partnerships in research - From its outset (and see letters of support) this research will engage policy makers, and the professionals, managers and carers that influence policy in a participatory approach to research. This will improve research and promote the value of research informed decision making in the long term while established collaborations are enhanced and new research linkages built to undertake multi-disciplinary, policy relevant work using a range of innovative methods. Particularly worthy of note are strengthened linkages between The Kenyan Ministry of Health and the Wellcome Trust's Kenya Major Overseas Programme and new linkages between it and The Said (Oxford) and Strathmore (Kenya) Business Schools and the Engineering and the Environment Department in Southampton.
Generalisable learning - Although empiric work focuses on Nairobi City County and its 5 million residents, the methods, results and approach will be of value across Kenya, East Africa and internationally. In particular, the innovative epidemiological modelling and examination of intervention delivery tasks and their complexity, the tools to be developed to do this, and the options for task-shifting that emerge will combine to offer an approach that is transferable to a number of fields. Furthermore, the approaches to framing findings within a specific context using stakeholder and ethnographic research approaches, linked to illustrative use of economic modelling, will be of considerable wider interest as methods to develop politically and organisationally feasible task-shifting interventions.
Capacity building - Throughout this project there is an emphasis on developing new disciplinary linkages and transferring skills to help build health systems research capacity amongst young investigators and absorptive capacity amongst policy makers and other partners. We anticipate at least 3 Kenyans undertaking PhD studies linked to this programme and multiple, important research, policy and practice outputs delivered by early career researchers supported by the senior team assembled to support work.

Publications

10 25 50

publication icon
Jepkosgei J (2019) Maintaining Distance and Staying Immersed: Practical Ethics in an Underresourced New Born Unit. in Journal of empirical research on human research ethics : JERHRE

 
Description • Multiple research approaches were used to develop an understanding of the context, coverage and quality of inpatient care for sick newborns in Nairobi, Kenya over a 4 year period, here we try to draw lessons from this body of work.
• Conducting this type of work and generating locally credible findings was only possible through extensive formal and informal stakeholder engagement spanning a diverse set of institutions and perspectives linked with an ability to adapt our research designs as findings emerged while keeping overall goals in mind.
• We found in a predominantly poor, urban population that when hospital care is needed for a sick newborn an estimated 45% cases do not access any suitable facility, that the public sector provides 70% of existing care and that private sector care is either very expensive or offers lower quality care through low-volume facilities.
• In the public and low-cost not-for-profit sectors critical nursing workforce shortages significantly undermine quality of care, patient safety and nurses' well-being. The provision of high quality care is almost impossible in these settings but working routines and norms have emerged that enable professionals to cope and that sustain the appearance of adequate care.
• In the short term a substantial increase in the number of health workers, especially nurses, is required to improve quality. To improve coverage and quality this must be combined with longer-term investment to redesign systems of care and improve information that supports effective governance.
Exploitation Route We provide clear evidence of what needs to be done to achieve improved quality and outcomes of neonatal hospital care in Kenya with findings of great relevance for the entire region
Sectors Education,Healthcare

URL https://www.tropicalmedicine.ox.ac.uk/wall-of-faces/mike-english-podcast-1
 
Description Our findings have been used to inform ongoing policy discussions about the need for improved professional staffing and support workers in Kenyan hospitals -policy discussions spanning multiple stakeholders. They have also been used to develop draft recommendations for strtegic development of neonatal health care services in Kenya.
First Year Of Impact 2017
Sector Healthcare
Impact Types Policy & public services

 
Description Co-design of a potential Neonatal Healthcre Assistant cadre
Geographic Reach National 
Policy Influence Type Participation in a advisory committee
 
Description Creation of National Neonatal Care Guidelines
Geographic Reach National 
Policy Influence Type Participation in a national consultation
Impact Our team was involved in undertaking systematic reviews and coordinating national guideline panels using GRADE & DECIDE methods to rewrite the national neonatal guidelines and standards of care. These will be nationally disseminated and used for in-service and pre-service training at a national scale for clinicians and nurses.
 
Description Development of Draft Standards for Neonatal Nursing Task Completion
Geographic Reach National 
Policy Influence Type Participation in a advisory committee
Impact Draft standards for the provision of neonatal nursing care were developed with national stakeholders. These provide a means to evaluate the quality of nursing care being delivered against these standards.
 
Description Draft national standards on Levels of Neonatal Care
Geographic Reach National 
Policy Influence Type Participation in a national consultation
Impact Not possible to attribute health impacts but our work has changed thinking on strategic planning of the health care system
 
Description Joint Health Systems Research Initiative - Development Grant
Amount £190,000 (GBP)
Funding ID MR/R018510/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 02/2018 
End 01/2020
 
Description Learning to Harness Innovation in Global Health for Quality Care (HIGH-Q)
Amount £3,595,229 (GBP)
Funding ID NIHR130812 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 09/2020 
End 09/2024
 
Description Wellcome Trust Research Training Fellowship
Amount £159,400 (GBP)
Funding ID 109943 
Organisation Wellcome Trust 
Department Wellcome Trust Research Training Fellowship
Sector Charity/Non Profit
Country United Kingdom
Start 03/2016 
End 03/2019
 
Title Health facility structural assessment tool 
Description This is a quantitative paper-based tool for evaluating the structural components of staffing, infrastructure, and equipment in health facility delivery wards and newborn units in Kenya. An electronic data capture tool has also been delivered in RedCap for data entry purposes. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact The tool allows for systematic evaluation of the structural components of health facilities in Kenya. This approach has allowed us to quantify the staffing structure, infrastructure, and availability of vital equipment for the delivery of care to newborns in the delivery/maternity wards and the newborn unit (for sick newborns) across all health facilities providing 24/7 inpatient care for sick newborns within Nairobi County, Kenya. 
 
Title Maternal admission register data entry tool 
Description This tool was developed in 'Research Electronic Data Capture' (REDCap) to electronically capture information from maternal admission registers in health facilities in Kenya. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact The tool has allowed us to quantify the number of maternal admissions across 34 health facilities in Nairobi, Kenya, and capture basic information about the women and the outcome of their delivery. 
 
Title Newborn admission register data entry tool 
Description This tool was developed in 'Research Electronic Data Capture' (REDCap) in order to capture information on admissions of sick newborns for inpatient care in health facilities in Kenya. It captures basic characteristics about the patient and information about the outcome of their admission. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact The tool has allowed us to quantify the number of newborn admissions across all health facilities in Nairobi, Kenya, which provide 24/7 inpatient newborn care. For these admissions, data captured provides information about the case-mix and outcomes of newborn patients across the county. 
 
Title Nursing questionnaire 
Description This is an electronic tool created in 'Research Electronic Data Capture' (REDCap). The tool is used for interviewing nurses 1 on 1 to assess their knowledge of Kenyan national guidelines with regard to care provided to newborns on the delivery/maternity ward and in the newborn unit (for sick newborns). There is a mixed of vignettes and specific knowledge-based questions. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact The tool has allowed us to assess the knowledge-base of nurses providing care to newborns at the point of delivery (on maternity wards) and sick inpatient newborns (in the newborn unit) across 34 health facilities in Nairobi, Kenya. 
 
Title Public access to research tools 
Description We have made all the tools used in recent large scale surveys of neonatal care publicly accessible 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2016 
Provided To Others? Yes  
Impact Just released 
URL https://globalresearchmethods.tghn.org/methodology-projects/estimating-gaps-provision-and-quality-in...
 
Title Nairobi Neonatal Study Data Collection Tools 
Description We utilised a large number of approaches to collect data on the structure, process and outcome attributes of neonatal care service provision across Nairobi's facilities. All these tools were developed in REDCap which is non-proprietary and used R scripts for data quality checking. These are being made available together with the standard operating procedures guiding data collection. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? Yes  
Impact At present it is too early to know. 
URL https://globalresearchmethods.tghn.org/methodology-projects/estimating-gaps-provision-and-quality-in...
 
Description Health Services that Deliver for Newborns 
Organisation Government of Catalonia
Department Department of Health
Country Spain 
Sector Public 
PI Contribution We coordinate this partnership and are providing capacity building to two Kenyans, one from Strathmore whom we are supervising to do a PhD and one from Nairobi City County whom we are supporting to do an MSc. Both are seconded to work full time on the research project
Collaborator Contribution Two full time staff to the research team - one as a PhD student one as a medical doctor
Impact This is a multidisciplinary collaboration spanning clinicians, epidemiologists, social scientists, economists the public and private sector in health and the county and national government.
Start Year 2015
 
Description Health Services that Deliver for Newborns 
Organisation Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH)
Country Kenya 
Sector Public 
PI Contribution We coordinate this partnership and are providing capacity building to two Kenyans, one from Strathmore whom we are supervising to do a PhD and one from Nairobi City County whom we are supporting to do an MSc. Both are seconded to work full time on the research project
Collaborator Contribution Two full time staff to the research team - one as a PhD student one as a medical doctor
Impact This is a multidisciplinary collaboration spanning clinicians, epidemiologists, social scientists, economists the public and private sector in health and the county and national government.
Start Year 2015
 
Description Health Services that Deliver for Newborns 
Organisation Strathmore University
Department Institute for Healthcare Management
Country Kenya 
Sector Academic/University 
PI Contribution We coordinate this partnership and are providing capacity building to two Kenyans, one from Strathmore whom we are supervising to do a PhD and one from Nairobi City County whom we are supporting to do an MSc. Both are seconded to work full time on the research project
Collaborator Contribution Two full time staff to the research team - one as a PhD student one as a medical doctor
Impact This is a multidisciplinary collaboration spanning clinicians, epidemiologists, social scientists, economists the public and private sector in health and the county and national government.
Start Year 2015
 
Description A quick introduction to the challenges of neonatal nursing 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We will be using a series of podcasts to explain our work over the coming 2 years and this is one example
Year(s) Of Engagement Activity 2016
URL http://www.tropicalmedicine.ox.ac.uk/jacob-mcknight-neonatal-nursing-in-kenya
 
Description Advisory meeting on essential neonatal tasks 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact The meeting was aimed at the nursing community and was attended by policy makers, practitioners and nurse trainers. Its aim was to engage in discussions on the essential neonatal tasks linked to the most relevant procedure standards from the Nursing Council of Kenya (NCK) manual and reach a consensus on what defines good quality. The group will meet again soon to firm up on updating the NCK manual.
Year(s) Of Engagement Activity 2015
 
Description Development of Draft Neonatal Levels of Care framework 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Professional associations, senior managers, policy makers, global agencies (WHO & UNICEF) and 3rd sector organisations (Save the Children, Clinto Health Access Initiative), university faculty together with practitioners to draft guidance on how neonatal care services should be organised into levels or tiers and define these levels.
Year(s) Of Engagement Activity 2018
 
Description Development of Draft Standards for Neonatal Nursing Care in Kenya 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact An expert gourp of policy makers, regulators and senior practitioners was brought together for 2 days and based on formative work conducted by the research team to draft standards for neonatal nursing care.
Year(s) Of Engagement Activity 2018
URL https://gh.bmj.com/content/3/2/e000645.info
 
Description Feedback meeting to Nairobi Health Care Providers 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact We held a feedback meeting with public sector, private sector and not-for profit providers from across Nairobi Count, local and national government and representatives from UNICF, Save the Children, PATH and others. Feedback on early study findings was provided and implications discussed with a round table event for funders and policy makers held in the afternoon.
Year(s) Of Engagement Activity 2016
 
Description Guidelines panel meeting (Limuru) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The Ministry of Health (MoH), Kenya Paediatric Association (KPA) and KEMRI-Wellcome Trust Research Programme (KWTRP) convened guideline panels to update recommendations in major areas of care for sick newborns. Systematic reviews were undertaken by KWTRP and MoH partners and the evidence formed the basis of discussions for 3 panels each of between 16 and 20 experts. This resulted in updates of the Basic Paediatric Protocols (BPP) pocket booklet - Jan 2016 edition. The booklet underwent validation through the MoH and partners on December 15th 2015 and is soon to be disseminated countrywide, by Feb 2016.
Year(s) Of Engagement Activity 2015
URL https://www.facebook.com/IDoc_Africa-554677441235162/
 
Description Health services that deliver for newborns 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Policy makers at the Nairobi City County (NCC), the Ministry of Health, key partners like the Kenya Paediatric Association and KWTRP researchers attended this meeting in Jan of 2015. Later, we co-opted a trainee researcher in May from NCC on attachment to KEMRI-Wellcome Trust to be part of the study team aimed at improving neonatal care in Nairobi county health facilities. We have so far (as of Jan 2016), made good progress in data collection in 31 health facilities within NCC. Other Additional research partners include the University of Nairobi, Strathmore University and some support coming from University of Oxford.
Year(s) Of Engagement Activity 2015
URL http://www.idoc-africa.org/index.php/en/102-home/143-hsdn
 
Description Meeting with expert nurses 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Workshop organised on the application of ergonomic methods for 3 days with Prof. Neville Stanton from Southampton and 14 expert nurses including senior representatives from the Ministry of Health
Year(s) Of Engagement Activity 2016
 
Description Multiple meetings with senior nursing regulators, professional associations and Ministry of Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact We maintain a continuous dialogues with policy makers, regulatory organisations and professional associations that govern nursing practice in Kenya to co-develop thinking on strategies to improve provision of neoantal hospital care and update them on emerging research findings
Year(s) Of Engagement Activity 2018
 
Description Post-dissemination meeting podcasts 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact After a feedback meeting for 75 people from facilities taking part in our research that also included policy makers we created 3 short podcasts expressing the views of some participants enabling us to share their views with the wider public
Year(s) Of Engagement Activity 2017
URL http://www.tropicalmedicine.ox.ac.uk/podcasts-on-nairobi-newborn-study
 
Description The Health Services, Implementation Research and Clinical Excellence Collaboration 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact The Ministry of Health's interest in future collaboration with KEMRI-Wellcome Trust in the area of capacity building on health systems research and implementation science research owing to results from the past collaboration of conducting hospital surveys. The Health Services, Implementation Research and Clinical Excellence collaboration (SIRCLE), provided training for young researchers drawn from or linked to the University of Nairobi, College of Health Sciences and the Ministry of Health. Funding enabled six trainees to work with SIRCLE for two and a half years during which they received formal training and undertook supervised research to build practical skills. Presentations in this forum were on: how to make evidence based guidelines; the draft 2015 neonatal and pneumonia guidelines; creating clinical information to inform policy and practice; what to look for in an electronic medical records system; using data to change practice and understand mortality
Year(s) Of Engagement Activity 2015
URL https://www.facebook.com/IDoc_Africa-554677441235162/