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.

Geospatial mapping of timely access to inpatient neonatal care and its relationship to neonatal mortality in Kenya

“…While a facility may have the necessary capacity, these structural indicators of quality ignore the important role of processes in high-quality service provision [59]. For example, a facility may have all the necessary resources but in inadequate quantities to cope with excess workloads or be unable to deliver care effectively at night or the weekend [65,66]. Third, some indicators such as staff availability may also be subject to variations from time to time and this may affect the selection of hospitals.…”

Improving facility-based care: eliciting tacit knowledge to advance intervention design

“…For example, our work has examined implementation experiences, 18 the work and influence of clinical and facility leaders, 19 20 how theory might inform intervention design, 21 how norms shape practice, 22 and efforts to diagnose micro, meso and macro health system challenges. 23 24 This work leads us to suggest first considering three foundational questions on the resources available in the contexts targeted for change, and how these might impact the delivery and outcomes of an intervention. In many LMICs, the quality, safety and thus outcomes of facility-based care are undermined by the challenges in three core resource areas: inadequate physical or material resources, deficits in workforce capacity and capability, and poor team and organisational relationships.…”

“You can't even ask a question about your child”: Examining experiences of parents or caregivers during hospitalization of their sick young children in Kenya: A qualitative study

“…The implications of these findings highlight the need to address structural issues and develop holistic sustainable solutions to ensure caregivers and their families remain central to care. In both Bungoma and Nairobi, shortages in nursing workforce, limited infrastructure, poor leadership, governance, and other issues have undermined the quality of care provided for sick young children (20,21,29,30). Ensuring providers are working in an enabling hospital environment that addresses staffing shortages, provides a supportive environment that includes mentorship, teamwork and supportive supervision as well as ensuring there are adequate supplies and equipment for providers to carry out their duties can improve the quality of care.…”

“…Caregivers in Kenya and Uganda who experienced stillbirths also reported poor interactions with health workers, lack of support and not being treated with compassion (19). Some of the drivers of newborn mistreatment include high patient workload in public health facilities, insufficient providers and limited infrastructure which may exacerbate poor service delivery (20). Previous research has shown that nurses who work in high-stress, low-resource environments with minimal managerial oversight may develop coping strategies, like closely monitoring high risk patients and rationing resources, facilitating limited direct emotional exposure to patients (21).…”