I'm Mike English, I'm Professor of International Child Health with the
Centre for Tropical Medicine and Global Health in Oxford,
but I have lived and worked in Kenya at the KEMRI Wellcome Trust Research Programme.
So the Health Services that Deliver for Newborns project was a set of multi-disciplinary work that
we wrote a proposal for way back in 2013, and we've been working on this area for four years,
and the idea of the Health Service for Newborns project was to take Nairobi County
as an example and really try and understand how care for sick newborn babies those that
require to be admitted to hospital, how its organised, what the capacity is,
what are the challenges of delivering it and what are some of the key quality issues.
Delivering high quality care is obviously a process that involves a huge number of
different people from policy makers through to senior practitioners who lead in direct things
through to those that actually provide the care, even the families themselves,
and so we wanted to try and understand all of these elements and we were particularly
concerned about, in some parts are trying to understand actually physically what's
the capacity of the system in Nairobi which serves a population of four and
a half million people of whom a very large number are from very low-income settings.
We were particularly in what the capacity was to provide the
right amounts of care since we know that in Nairobi neonatal mortality,
that's the number of babies who died in the first month of life, is extremely high.
One of the major parts of this project was to try and understand the capacity to
provide care for this Nairobi population and a lot of this work was led by a colleague of
mine called dr. Gina Murphy, but working with a large set of Kenyan researchers,
and one of the things we had to do first was establish how much care is actually needed
and we had to do that by using epidemiological approaches by using lots of research findings
that have estimated how many babies might get sick from particular conditions,
and so we pulled together lots of this epidemiological research and made an
estimate based on the number of births we know happen in Nairobi County to suggest
how many babies would need to access hospital services, so that was one key piece of work.
Then what Gina and the team with David and others in the team, what they did was actually identify
all the facilities that were expected to provide inpatient care for sick babies,
that's those babies that needed to spend one or two or three or even sometimes many more nights
in hospital receiving care, that was quite a bit of work to identify all of those, to reach
out to them, to ask if they would be happy for us to engage them in the research, and then actually
using tools go out and try and characterise fully what they're capable of doing and the
resources they have and some of their practices, so that was about actually trying to assess the
readiness of the system to offer care to the sick newborns that we know will likely be needing it.
The final thing we do is check whether the medical care that was being provided was of
a good standard, and we used as a standard there the National recommendations for how neonatal
care should be provided, so we had several sets of work all building up to help us understand
if you were a sick newborn in Nairobi, that you may be within six or 12 hours of birth,
that baby needs to be admitted to hospital, we were able to estimate how much care is
available to them and our estimates suggest that probably forty to forty-five percent of
babies who should get to a good Hospital for care probably never make it at all,
of the ones that do make it to the hospital we estimate that only half of those actually
are admitted to a hospital which is ready to provide good quality care, so what that
means in reality is that of all the babies that perhaps should get into a good hospital for care,
only about one-quarter actually make it to a place which can provide good quality care.
That was a whole set of work which is what we call effective coverage
so we think that's one of our key results is that effective coverage
is only available for 25% of babies who need hospital care in Nairobi County.
Further work, and I think my colleagues are talking about this, went on to then
investigate nursing care which wasn't captured in this initial set of estimates and we now know
from the nursing care work and evaluating that, that even that what I said was 25% might access
a place ready to provide good care, even if they reach those places the challenges
with nursing care are so profound that most babies probably don't get high-quality care.
Some of the key priorities we've identified in one sense may not be revolutionary, but
we've really been able to provide information to underline their importance - absolutely critical
is we need more nurses; the number of nurses are available to provide care to these sick newborns
is just too few, so that's an absolutely critical need, however what we've also found is that the
system of care for this population needs to be much better organised and we probably need to
think about different levels of care - what we've seen is that the majority of people,
and obviously particularly the poor people, tend to use the government provided services
and they're completely overstretched, and so what we need to do is strengthen the existing
facilities, but probably also think of ways in which we can add new facility-based care,
maybe in smaller places, better distributed around the county, and so that they can provide
some basic forms of hospital care for newborns and if they're unable to provide more advanced
care then we need systems where the babies and the mothers can be moved to a hospital where
that care can be better provided, so there are actually quite major long-term strategic issues
for the healthcare system in Nairobi, and we think probably for the rest of the country,
in how we're going to provide these services, so there's issues of the infrastructure we need,
systems we need to move people from one place to another, should they need more advanced care,
and then critically, the human resources that we have able to offer those care.
This project has brought together epidemiologists, clinicians like
myself as a paediatrician, it's brought together social scientists including anthropologists,
it's brought together statisticians, and we've been working with policymakers,
with senior professionals, with regulators, and I think what it's shown us is that you need to
make very special efforts to bring these groups together, to help them understand each other,
each piece of work has its own methodology or approach, but it's important that other
parts of the team understand the value of those methods and it's also helped us to
understand that these are long-term processes, and we're learning as we go and it's been very
important we feel to bring our stakeholders - those organisations I've mentioned - together
on this journey because I think we're in a better place now to continue doing further
multi-disciplinary work going forwards to tackle many of the issues that we've now uncovered.