Developing Recommendations for Neonatal Inpatient Care Service Categories: Reflections from the Research, Policy and Practice Interface in Kenya
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Practice Developing recommendations for neonatal inpatient care service categories: reflections from the research, policy and practice interface in Kenya Claire Marriott Keene,1,2 Jalemba Aluvaala,2,3 Georgina A V Murphy,1,2 Nancy Abuya,2,4 David Gathara,2,5 Mike English,1,2 On behalf of the Health Services that Deliver for Newborns Expert Group To cite: Keene CM, Aluvaala J, ABSTRACT Summary box Murphy GAV, et al. Developing Neonatal deaths contribute a growing proportion to recommendations for childhood mortality, and increasing access to inpatient ► There has been an absence of strategic thinking neonatal inpatient care newborn care has been identified as a potential driver of service categories: reflections on the development of inpatient neonatal services improvements in child health. However, previous work from the research, policy in Kenya. This is likely to limit provision of essential by this research team identified substantial gaps in the and practice interface in interventions at scale as part of efforts to improve coverage and standardisation of inpatient newborn care Kenya. BMJ Glob Health newborn survival. 2019;4:e001195. doi:10.1136/ in Nairobi City County, Kenya. To address the issue in this ► Presentation of collated evidence to stakeholders, particular setting, we sought to draft recommendations bmjgh-2018-001195 with whom the research group had a long-stand- on the categorisation of neonatal inpatient services ing relationship, and the use of a modified nominal through a process of policy review, evidence collation Handling editor Seye Abimbola group technique to facilitate consensus, was a pro- and examination of guidance in other countries. This Additional material is ductive and acceptable approach to drafting health ► work supported discussions by a panel of local experts published online only. To view service recommendations in the Kenyan context and representing a diverse set of stakeholders, who focused on please visit the journal online might usefully be replicated in other settings. formulating pragmatic, context-relevant guidance. Experts (http:// dx. doi. org/ 10. 1136/ ► Consideration of the tensions surrounding choic- in the discussions rapidly agreed on overarching priorities bmjgh- 2018- 001195). es, clarifying the perspective to be adopted and a guiding their decision-making, and that three categories focus on pragmatism helped achieve most deci- of inpatient neonatal care (standard, intermediate and sion-making goals within achievable time con- Received 26 September 2018 intensive care) were appropriate. Through a modified straints. However, there was some tension between Revised 6 December 2018 nominal group technique, they achieved consensus pragmatic and aspirational recommendations that Accepted 7 December 2018 on allocating 36 of the 38 proposed services to these led to a lack of consensus on certain services, and categories and made linked recommendations on efforts to promote consensus-based decision-mak- minimum healthcare worker requirements (skill mix and ing did not entirely overcome the potential influence staff numbers). This process was embedded in the local of high-status experts. context where the need had been identified, and required ► Embedding research groups within health policy and only modest resources to produce recommendations delivery systems helps develop understanding of the on the categorisation of newborn inpatient care that the context and the ability to facilitate evidence informed experts agreed could be relevant in other Kenyan settings. decision-making discussions. However, researchers Recommendations prioritised the strengthening of existing can also introduce their own biases, making trans- facilities linked to a need to develop effective referral parent reporting of processes important. systems. In particular, expansion of access to the standard category of inpatient neonatal care was recommended. The process and the agreed categorisations could inform discussion in other low-resource settings seeking to effective delivery of essential newborn inter- address unmet needs for inpatient neonatal care. ventions could decrease neonatal mortality by 71%, and that 82% of this reduction could be © Author(s) (or their employer(s)) 2019. Re-use achieved by optimising delivery of inpatient 2 permitted under CC BY. care. Published by BMJ. INTRODUCTION Improving the organisation of inpa- For numbered affiliations see As targeted interventions reduce the preva- tient newborn services is a major health end of article. lence of common causes of childhood death system concern, particularly in low-income Correspondence to (eg, diarrhoea and pneumonia), newborn and middle-income countries (LMICs) Dr Claire Marriott Keene; deaths contribute a growing proportion of such as Kenya, where neonatal mortality clairekeene@ gmail. com under-five mortality.1 Estimations suggest that is high. Regionalisation of services, with Keene CM, et al. BMJ Glob Health 2019;4:e001195. doi:10.1136/bmjgh-2018-001195 1 BMJ Global Health concentration of resources at higher levels, has been additional 30.4% access inadequate inpatient services.16 17 suggested to improve service quality and efficiency and Importantly, only 4 of these 31 facilities are in the public maintain staff skills.3–5 This centralisation of services sector (three level 4/5 and one level 6 hospital), but they relies on a well-functioning referral network; otherwise, it are responsible for 71% of the newborn admissions in loses its benefits and its disadvantages are compounded.6 the county, resulting in severe overcrowding and low However, the Kenyan referral system currently faces many nurse:patient ratios.15 17 challenges, including a lack of written policy on trans- Governance of health service delivery in Kenya was port logistics and financing, no coordination structure devolved to county level in 2010; however, work in the to oversee the implementation of the national referral Nairobi context has implications for Kenya as a whole, strategy and a lack of quality standards and monitoring with policy and capacity building remaining the respon- of referral service performance.7 Alternatively, decentral- sibility of the national government.18 19 The national isation of services to lower-level facilities may reduce the Ministry of Health has prioritised strategic development burden on overcrowded higher-level facilities, increase of public neonatal services to improve access and quality of access and improve responsiveness to local needs.8–10 care for newborns, particularly necessary for low-income Since the Toward Improving the Outcome of Pregnancy groups that typically rely on the public sector.20 Previous report in 1976, regionalised, hierarchical systems of work revealed a lack of standardisation of newborn inpa- newborn inpatient care have predominated.3 However, tient services and the absence of formally agreed referral a 2014 systematic review found that evidence originated systems in Nairobi, thus technical guidance on the scope only from high-resource settings and was mostly of poor of newborn services that should be offered by facilities quality, making it insufficient to make causal claims on the could help inform strategies for service expansion.14 relationship between regionalisation and the improve- The first step to address the need for expansion of ments seen in perinatal outcomes.1 Research into health services and improvement in quality was to develop systems is inherently complex and the implementation recommendations defining categories of neonatal inpa- of regionalisation coincided with other improvements tient services applicable to the different facility levels likely to influence neonatal outcomes in higher-income in Nairobi City County. To achieve this, we set out to settings (generalised improvement in socioeconomic critically review existing Kenyan policy documents and status, the introduction of new treatments and overall normative guidelines to identify and incorporate existing investments in health systems) and overlapped with a recommendations relevant to newborn services, and global decrease in neonatal mortality that transcended identified examples of efforts to define categories of different system structures.1 11 This lack of quality newborn inpatient care applicable to lower resource evidence to guide structural organisation of neonatal settings that could inform Kenyan discussions. We used inpatient systems is a barrier to service improvement, this evidence to engage key stakeholders in order to particularly in resource-constrained settings. develop draft recommendations defining categories of neonatal inpatient care, drawing on their experience and context knowledge. CONTEXT The Kenyan health system is hierarchical with commu- nity-based care at level 1 and facilities arranged from APPROACH dispensary clinics and health centres (levels 2 and 3, Critical review of existing Kenyan policy and normative respectively) to tertiary hospitals (level 6). County hospi- guidelines tals (formerly district hospitals), where much of the inpa- We examined 12 documents spanning national strategic tient newborn care is provided, form levels 4 and 5.12 plans, clinical guidelines, human resource recommenda- Emergency Obstetric and Neonatal Care (EmONC) cate- tions and quality of care policies (online supplementary gories have been integrated into the thinking on levels of appendix table A1). Policy documents support improved care in Kenya: basic EmONC should be provided in level newborn care as a priority