Improving neonatal health in remote rural areas in China and Vietnam

Newborn (first 4 weeks of life) health remains a significant problem in China and Vietnam, especially in rural areas where they are 3 to 4 times more likely to die than in more developed areas. Most newborns can be treated with cost-effective interventions at facility and community levels, which do not require high-level training or costly equipment. Achieving high coverage of these interventions in the poorest areas could reduce neonatal deaths by at least 70%. While NH practice guidelines exist in China and Vietnam at national and local levels to guide on appropriate care and treatment, a major problem is ineffective implementation of the guidelines.
This development study will assess the feasibility of using a participatory problem-solving intervention with local health managers to improve NH guideline implementation. If feasible, it will inform the design of a full-scale study to evaluate the effectiveness of the intervention. In the full-scale study, the research team would support local health managers through problem-solving and planning workshops, mentoring and capacity development to (1) assess the effectiveness of current guidelines; (2) identify barriers to improved implementation relating to service delivery (e.g. workforce issues, transport, equipment and supplies) and service demand (limited by remote access and traditional beliefs); (3) develop feasible strategies within current resource constraints e.g. re-organising services and the workforce, and using suitable community engagement models to stimulate demand for improved services; and 4) develop appropriate methods to monitor impact and unintended consequences.
To assess the intervention's feasibility in remote, rural China and Vietnam the development study must address 4 questions:
1. What are the current health service management practices and the degree of freedom for decision-making at different systems levels for improving NH outcomes?
2. What are the opportunities for developing or strengthening community actions to support improved NH outcomes?
3. What is the potential for monitoring NH outcomes and measuring cost-effectiveness of interventions at different health systems levels?
4. What is the feasibility for local managers to use a participatory problem-solving intervention to implement existing practice guidelines for improving NH outcomes covering community, primary and referral levels and what would be the best vehicle for the intervention?
We plan to conduct desk-based reviews of NH practice guidelines, challenges of monitoring NH impact in remote areas and NH intervention cost-effectiveness, before holding a 2-day workshop in Beijing to refine our field work plan and data collection tools and conduct 3 national key informant interviews (KIIs). We will then collect data in Guizhou, China using 4 methods: (i) KIIs: community level representatives, local health service managers, frontline health workers and provincial level policy makers and senior health officials; (ii) focus group discussions: recent mothers and community members; (iii) document review of community action agreements and provincial/national policies and plans; (iv) observation of health management information systems (HMIS) and accounting systems. A smaller research team will repeat this data collection protocol in Tay Nguyen, Vietnam, before analysing the two country datasets.
This will inform the design the full-scale study and facilitate stakeholder engagement. We will produce 3 outputs on monitoring NH services in remote areas; practicalities of monitoring NH in remote China and Vietnam; and national policy space and local decision making freedom to improve NH services. Three levels of stakeholders will benefit: local (health service managers and staff), national (policy makers in China's MCH centres and Vietnam's NH technical working group) and international (e.g. Unicef, WHO, PMNCH and implementation science groups like WHO-led Implementation Research Platform).

Objective: Assess the feasibility of a participatory problem-solving intervention to improve use of available practice guidelines to improve neonatal health in rural China and Vietnam

Design: Qualitative
Methods: Stage 1:Conduct 3 desk-based reviews: global neonatal health (NH) practice guidelines; challenges and methods of monitoring NH impact in remote rural areas; and cost-effectiveness of NH interventions. Stage 2:Conduct 3 national key informant interviews (KIIs) in Beijing. Stage 3:In Guizhou, China collect data on health service management practices, community actions to support improved NH outcomes, health service information systems, costing, and assess the feasibility of larger full-scale intervention. This uses 4 methods: (i) 12 KIIs: community level representatives e.g. community workers, local health committee members [n=3]; local health service managers [n=3], frontline health workers [n=3] at primary and referral levels; and policy makers [n=2] and senior health service officials [n=1] at provincial level; (ii) 2 focus group discussions: 1 with mothers who have delivered in the past 2 years and 1 with community members; (iii) Document review of local community action agreements and provincial and national policies and plans to assess policy space to implement the full scale intervention; and (iv) Observation of systems practice in the local health management office and 3 health facilities: review health management information systems (HMIS) to identify potential for monitoring NH outcomes and accounting systems to identify cost data. Stage 4: Repeat the data collection protocol in Tay Nguyen, Vietnam.
Data analysis & outputs: Analyse country data using framework based on the questions and emergent themes. Produce outputs on global review of monitoring NH services in remote areas; briefs on a) practicalities of monitoring NH in remote areas of China and Vietnam and b) national policy space and local decision making freedom to improve NH services.

This development study will assess the feasibility of using a participatory problem-solving intervention with local health managers - planned as part of a larger full scale study - to improve implementation of neonatal health guidelines in remote rural areas of China and Vietnam, where NH indicators are poor. Not only do poor NH outcomes have sometimes catastrophic impact on mothers, neonates and families but there are wider social and economic implications. Sufficient knowledge about required clinical and household care is available through evidence-based practice guidelines, but these are not being used effectively in preventive or curative NH practice. If a participatory problem-solving intervention is effective in improving NH practices, it will have direct impact on stakeholders in the study sites. If the intervention is subsequently adopted for use on a wider scale, these impacts will benefit more stakeholders in remote rural areas ultimately improving the NH indicators in these areas and being of a wider benefit to society. The beneficiaries of the full-scale intervention include: pregnant women and children in study sites (including currently excluded service users) and their families; health service staff and managers and informal health care providers (including private sector providers) who could carry out their work more effectively; provincial and national programme managers and policy-makers, or more remote areas of China and Vietnam, if the intervention is scaled-up; and international organisations and researchers with interests in improving NH outcomes and advancing knowledge in implementation science. Implementation research is much-needed and immensely important in understanding how to deliver NH care and treatments effectively within existing health systems, and in helping "implementers" foresee and overcome problems.
The development grant to assess the feasibility of the full-scale intervention will positively impact the following beneficiaries:
Health service managers at facility, referral and provincial levels in study sites will potentially benefit through the interviews by gaining greater awareness of the potential for improving implementation and monitoring of practice guidelines and linking community actions and service delivery improvements to maximise impact.
National policy-makers in China and Vietnam will benefit from the availability of the briefing notes and face-to-face briefings with the national research teams on potential methods to address guideline implementation challenges. Policy-makers should gain greater awareness of the potential for improving implementation of guidelines and tools and linking community actions and service delivery improvements; the challenges and opportunities for monitoring the impact of interventions on neonatal health; and availability of guidelines and tools for improving neonatal health.

International organisations and academics will benefit from the global review of monitoring NH services in remote areas, which will be a high-quality synthesis of knowledge and evidence from peer reviewed publications. In particular, we will engage with the WHO Implementation Research Platform membership to share our assessment of the feasibility of the participatory intervention and our findings on the degree of freedom for decision-making at different systems levels.