Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya

Abstract

There are global calls for research to support health system strengthening in low-income and middle-income countries (LMICs). To examine the nature and magnitude of gaps in access and quality of inpatient neonatal care provided to a largely poor urban population, we combined multiple epidemiological and health services methodologies. Conducting this work and generating findings was made possible through extensive formal and informal stakeholder engagement linked to flexibility in the research approach while keeping overall goals in mind. We learnt that 45% of sick newborns requiring hospital care in Nairobi probably do not access a suitable facility and that public hospitals provide 70% of care accessed with private sector care either poor quality or very expensive. Direct observations of care and ethnographic work show that critical nursing workforce shortages prevent delivery of high-quality care in high volume, low-cost facilities and likely threaten patient safety and nurses' well-being. In these challenging settings, routines and norms have evolved as collective coping strategies so health professionals maintain some sense of achievement in the face of impossible demands. Thus, the health system sustains a functional veneer that belies the stresses undermining quality, compassionate care. No one intervention will dramatically reduce neonatal mortality in this urban setting. In the short term, a substantial increase in the number of health workers, especially nurses, is required. This must be combined with longer term investment to address coverage gaps through redesign of services around functional tiers with improved information systems that support effective governance of public, private and not-for-profit sectors.

Keywords: child health; epidemiology; health services research; health systems evaluation; paediatrics.

Figure 1

Guiding the research team’s work were key principles that to identify appropriate solutions a deep understanding of the setting or context and the stakeholders who shape the health system are required.

Figure 2

Schematic representation of the research and engagement activities conducted as part of the Health Services that Deliver for Newborns (HSD-N) Programme. The HSD-N Programme was designed and implemented in three phases for simplicity illustrated as distinct but, in reality, overlapping. Of these, phase two was the longest. Throughout researchers from different disciplinary backgrounds interacted and where appropriate collaborated. A major thrust of the quantitative research was to combine evaluations to develop a better understanding of how likely it was that a sick newborn would receive quality inpatient care in Nairobi. This was complemented by detailed qualitative work that explored the reality of newborn ward hospital care, how nurses in particular coped with and families experienced such a high-pressure environment. All forms of data informed stakeholder discussions and development of draft policy proposals. HCA, healthcare assistant.

Figure 3

Illustrating the likely cascade of coverage with and quality of essential inpatient care for sick newborns in Nairobi City County. With a target population of sick newborns likely to need inpatient care of 21 966 in the year 2018, we used multiple data sources to estimate proportions (x-axis) accessing care represented as an ordered cascade of progressively more stringent quality criteria. In this approach, probability estimates from different studies are multiplied as additional quality criteria are introduced to provide an indication of the points, or steps, in the cascade where coverage and quality gaps have most impact on the reference population (the initial bar). The criteria we sequentially introduce are: (1) service contact: the proportion reaching a facility potentially capable of offering such care based on our survey of all neonatal unit admissions in a year; (2) service readiness: the proportion of those accessing care that reach a facility that has a minimum set of resources to support essential care; (3) basic quality-adjusted coverage: the proportion reaching a facility with needed resources who are then likely to receive technically competent medical care; and (4) public sector nursing care adjusted coverage, which further adjusts for the likelihood that nurses in public sector hospitals that provide >70% of inpatient newborn care will be able to complete 80% or more of tasks comprising a minimum standard of nursing care. (Estimated probabilities used in constructing the cascade are derived from previously published work.23 26 30).

Figure 4

Overview of research programme findings using the High Quality Health Systems in the Sustainable Development Goal Era framework to illustrate that addressing multiple system weaknesses is likely to be necessary to deliver high-quality care at scale and reduce high neonatal mortality. In this figure, challenges spanning the five platforms at the base of the figure are summarised. These undermine the system’s ability to learn and improve and contribute to inadequacies in the processes of care. All influence the observed outputs of the system (central shaded oval) that are on the pathway to the health impacts the system currently achieves.