Guideline Adherence in Slums Project - Template-based documentation and decision support for primary healthcare clinics in the private sector

With large numbers of people in slums seeking care through the private sector, it is important to develop tools to help providers in these clinics improve the quality of their services. For example, documenting the need for an antibiotic helps reduce the number of cases of unnecessary antibiotic prescriptions.

Clinical practice guidelines (CPGs) are tools developed to help doctors and nurses give evidence-based care. These are however not easy to use in a patient-facing scenario (e.g. a doctor looking through a manual when the patient is seated in front of him/her). They also need to be tweaked to be relevant to the local context (e.g. is the first line drug available or affordable?). For CPGs to be relevant in low-resource settings it is important to address multiple, if not all, barriers to using guidelines, but in a manner that does not strain limited resources.

Our intervention involves working with clinical care providers and developing templates (think checklist) that can be used while they are seeing the patient. The templates take the form of rubber stamps that can be printed into the paper case sheet (e.g. if a woman presents with increased frequency of urination, the clinician stamps the Urinary Tract Infection template into her case sheet). This template is both a guide to what questions to ask the patient and how to manage UTIs. Other illnesses get other templates, but a set of 6-8 templates covers the majority of patients walking into primary care clinics.

Importantly these templates are easy to digitise and analyse. They are in the form of a multiple choice exam paper where bubbles need to be shaded. A cell phone image of a filled-in template can quickly give us data on how the case was managed without revealing patient identity. Being rubber stamps we avoid the need to keep track of multiple printed sheets of paper. We also avoid wastage when guidelines change because changing the rubber engraving on the stamp is simple and cheap.

We now have a tool to easily monitor the clinician's work, check for quality, and work with them if there are reasons to deviate from the guidelines by during regular feedback sessions. The intervention is being used in two slum clinics in Nairobi with great initial responses.

We now want to study this intervention in a set of 10 different private sector clinics in Nairobi's slums. We would like to test if this intervention is:
a) Usable - different clinics have different priorities and attitudes and we need to be sure that the intervention poses no big challenges
b) Effective - does the intervention actually improve clinical practice (e.g. by reducing unnecessary antibiotic prescription)?
c) Sustainable - how much does it cost for us to support these clinics with tools and feedback? Can the clinics afford to pay us for this service?
d) Scalable - is there a realistic chance for us to roll this intervention out at national (or even provincial) level?

If successful the intervention has the potential to change how healthcare is delivered in low-resource settings. More and more people are seeking care in the private sector, but very few regulations, services and tools exist to ensure that care in the private sector is of high quality. We hope to make a significant impact in the quality of care that is delivered to the poor.

This study employs an exploratory sequential mixed methods research design with phased, concurrent data collection. The challenges of providing quality healthcare are highly complex especially in LMICs that face multiple health system shortcomings.

Phase 1 (Exploration): Understanding the challenges in implementing currently prescribed national (or international/WHO) guidelines in low-resource urban settings. This aspect will be addressed by a set of in-depth interviews (IDIs) with the following set of stakeholders involved in the implementation of guideline recommendations:

Phase 2 (Implementation): This phase includes two intervention elements:
a) Developing CPG-based templates (in rubber stamp format) for a set of commonly encountered conditions in adults.
b) A clinical audit and feedback system to review and aid providers in their adherence to CPGs (and templates).

Phase 3 (Paths to scale): This phase will explore scaling of the intervention using IDIs with clinic managers, managers of social enterprise clinic chains and FBOs, health managers of county governments, healthcare financiers, funders and policy makers.

This research approach explores both, the technical aspects of quality improvement interventions and also issues that affect the adoption of such interventions. Understanding the context in which the research is being conducted (eg. clinic financing, provider incentives, etc.), and also the paths to scale (and impact) is a central to our proposal and aims to maximise the chances of success of any larger research and/or implementation project in the future.

Who will benefit from this research?

In the short term:
1. Clinical care providers and managers of clinics in resource-constrained settings in LMICs. Most clinics in low-resource settings in Kenya are staffed by nurses and clinical officers who appreciate support in guiding their practice. Our initial efforts in Access Afya clinics have been highly rewarding with clinicians embracing principles of evidence-based practice. The templates are very useful tools for clinical practice that other clinics can benefit from.

In the medium term:
1. Researchers of healthcare quality, healthcare financing and health policy.
2. Health policy makers
3. Health researchers in Kenya
4. Innovators in healthcare
5. Individuals and communities in low-resources settings like slums

How will they benefit from this research?

1. Clinical care providers and managers of clinics can benefit from an approach to improve clinical care quality that is potentially highly effective, easily implemented and cheap.

2. Researchers in healthcare quality, financing and policy can benefit from the results of the study. Healthcare quality is closely related to financing and health policy makers can benefit from efforts to improve quality at low cost.

3. The project proposed here is a good example of implementation research. This is an important area of research in a country like Kenya which is a test bed for numerous interventions. There is very little learning from the numerous interventions that are undertaken. More implementation research is needed in Kenya to ensure that lessons are learned and mistakes are not repeated.

4. The intervention itself has implications on multiple fields including healthcare innovation in resource-constrained settings. The intervention has been designed with a number of constraints in mind, and incorporates learnings from health systems, human behaviour, health economics and technology. The research will benefit the field of frugal innovation by documenting successful principles.

5. The ultimate beneficiaries of the research are individuals and communities in low-resource settings in countries like Kenya. Healthcare for the poor is currently highly inaccessible in many dimensions. The are huge gaps in their abilities to perceive their healthcare needs, seek appropriate care, reach healthcare, pay for care or engage the providers. If healthcare in LMICs is to become more patient-centred, as in developed countries, it is important to support primary care providers and improve the care they deliver.