Effective coverage and budget implications of skill-mix change to improve neonatal nursing care: an explorative simulation study in Kenya

Abstract

IntroductionNeonatal mortality is an urgent policy priority to improve global population health and reduce health inequality. As health systems in Kenya and elsewhere seek to tackle increased neonatal mortality by improving the quality of care, one option is to train and employ neonatal healthcare assistants (NHCAs) to support professional nurses by taking up low-skill tasks.MethodsMonte-Carlo simulation was performed to estimate the potential impact of introducing NHCAs in neonatal nursing care in four public hospitals in Nairobi on effectively treated newborns and staff costs over a period of 10 years. The simulation was informed by data from 3 workshops with >10 stakeholders each, hospital records and scientific literature. Two univariate sensitivity analyses were performed to further address uncertainty.ResultsStakeholders perceived that 49% of a nurse full-time equivalent could be safely delegated to NHCAs in standard care, 31% in intermediate care and 20% in intensive care. A skill-mix with nurses and NHCAs would require ~2.6 billionKenyan Shillings (KES) (US$26 million) to provide quality care to 58% of all newborns in need (ie, current level of coverage in Nairobi) over a period of 10 years. This skill-mix configuration would require ~6 billion KES (US$61 million) to provide quality of care to almost all newborns in need over 10 years.ConclusionChanging skill-mix in hospital care by introducing NHCAs may be an affordable way to reduce neonatal mortality in low/middle-income countries. This option should be considered in ongoing policy discussions and supported by further evidence.

Management of human resources for health: implications for health systems efficiency in Kenya

“…This will need to be done while appreciating the fiscal constraints that counties face. Options for optimizing resources use in HRH such as task shifting may close gaps in health workers quantities cost-effectively [ 52 ]. Second, counties should review and seek to resolve funding flow challenges that contribute to delays of salary payments to health workers.…”

The paediatrician workforce and its role in addressing neonatal, child and adolescent healthcare in Kenya

“… 26–28 This may include greater attention paid to the development of clinical officers, nurses and even healthcare assistants with specific neonatal, paediatric and adolescent health skills to produce the most cost-effective skill-mix options to strengthen systems of paediatric care. 29 It may require a reimagining of the role of county paediatricians as abilities to plan, monitor, manage and lead multidisciplinary teams may become key skills. Such strategic shifts may require a major revision or diversification of existing postgraduate training curricula and continuous professional development strategies.…”

“…This should include thinking about how paediatricians might work with a wider multiprofessional team that considers innovative options for task-sharing, an area of active policy development in Kenya 26–28. This may include greater attention paid to the development of clinical officers, nurses and even healthcare assistants with specific neonatal, paediatric and adolescent health skills to produce the most cost-effective skill-mix options to strengthen systems of paediatric care 29. It may require a reimagining of the role of county paediatricians as abilities to plan, monitor, manage and lead multidisciplinary teams may become key skills.…”

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

“…Thus, frontline nurses were concerned with alleviating the intense workplace pressure that undermines their relationships with families and results in missed care and with the additional work effectively delegating and supervising HCA might create. As our discussions continued, simulations of how task sharing might be used to support an expansion in the nursing workforce to help achieve coverage and quality goals most efficiently proved an effective and stimulating way to engage with stakeholders 39…”

“…Increasing nurse numbers would likely benefit newborns, their families and staff well-being. HCAs are not a substitute for nurses but together with additional nurses might offer a useful skill-mix solution in some settings to improve quality and coverage relatively efficiently 39. However, introducing HCA is not a simple technical solution, and studies to explore any impact they have on quality, safety, teamwork and families’ experiences are required as a precursor to any widespread deployment.…”