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

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.

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.

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.