Abstract
BackgroundDistrict hospital services in Kenya and many low-income countries should deliver proven, effective interventions that could substantially reduce child and newborn mortality. However such services are often of poor quality. Researchers have therefore been challenged to identify intervention strategies that go beyond addressing knowledge, skill, or resource inadequacies to support health systems to deliver better services at scale. An effort to develop a system-oriented intervention tailored to local needs and context and drawing on theory is described.MethodsAn intervention was designed to improve district hospital services for children based on four main strategies: a reflective process to distill root causes for the observed problems with service delivery; developing a set of possible intervention approaches to address these problems; a search of literature for theory that provided the most appropriate basis for intervention design; and repeatedly moving backwards and forwards between identified causes, proposed interventions, identified theory, and knowledge of the existing context to develop an overarching intervention that seemed feasible and likely to be acceptable and potentially sustainable.Results and discussionIn addition to human and resource constraints key problems included failures of relevant professionals to take responsibility for or ownership of the challenge of pediatric service delivery; inadequately prepared, poorly supported leaders of service units (mid-level managers) who are often professionally and geographically isolated and an almost complete lack of useful information for routinely monitoring or understanding service delivery practice or outcomes. A system-oriented intervention recognizing the pivotal role of leaders of service units but addressing the outer and inner setting of hospitals was designed to help shape and support an appropriate role for these professionals. It aims to foster a sense of ownership while providing the necessary understanding, knowledge, and skills for mid-level managers to work effectively with senior managers and frontline staff to improve services. The intervention will include development of an information system, feedback mechanisms, and discussion fora that promote positive change. The vehicle for such an intervention is a collaborative network partnering government and national professional associations. This case is presented to promote discussion on approaches to developing context appropriate interventions particularly in international health.
Highlights
District hospital services in Kenya and many low-income countries should deliver proven, effective interventions that could substantially reduce child and newborn mortality
Throughout this process, the following questions guided thinking: Why is widely available practice guidance not reliably being used in district hospitals? What aspects of the current health system configuration are supporting or failing to support improved service delivery? On whom does service delivery improvement most depend? How does the system supporting service delivery improvement need to change, and at what system levels, to promote improvement in the absence of significant changes in material or human resources? Which interventions would fit best into existing structures and foster acceptable, feasible, and potentially sustainable evolution of the health system supportive of improved care? Potential intervention strategies were further refined through ongoing discussions with policy makers, senior professionals, and colleagues
Root causes of poor service delivery Practices have improved with the guideline dissemination efforts outlined above and other initiatives
Summary
District hospital services in Kenya and many low-income countries should deliver proven, effective interventions that could substantially reduce child and newborn mortality. Many African countries are not on track to achieve them [2] with a major obstacle being inadequate delivery of evidence-based, essential interventions that are one aspect of highquality care [3,4] Improving their delivery requires broad strengthening of national health systems [5,6,7] as a multitude of factors may influence how services are delivered including: financing, human resources, governance and information systems in addition to more traditional concerns over knowledge, skills, and availability of technologies [8,9]. Ill newborns or children with severe malnutrition are often not fed appropriately and drug dose errors remain common [25]
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