Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF.

BACKGROUND: Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC). METHODS: Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021. RESULTS: Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2-34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania. CONCLUSION: This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action.

Neonatal inpatient dataset for small and sick newborn care in low- and middle-income countries: systematic development and multi-country operationalisation with NEST360.

BACKGROUND: Every Newborn Action Plan (ENAP) coverage target 4 necessitates national scale-up of Level-2 Small and Sick Newborn Care (SSNC) (with Continuous Positive Airway Pressure (CPAP)) in 80% of districts by 2025. Routine neonatal inpatient data is important for improving quality of care, targeting equity gaps, and enabling data-driven decision-making at individual, district, and national-levels. Existing neonatal inpatient datasets vary in purpose, size, definitions, and collection processes. We describe the co-design and operationalisation of a core inpatient dataset for use to track outcomes and improve quality of care for small and sick newborns in high-mortality settings. METHODS: A three-step systematic framework was used to review, co-design, and operationalise this novel neonatal inpatient dataset in four countries (Malawi, Kenya, Tanzania, and Nigeria) implementing with the Newborn Essential Solutions and Technologies (NEST360) Alliance. Existing global and national datasets were identified, and variables were mapped according to categories. A priori considerations for variable inclusion were determined by clinicians and policymakers from the four African governments by facilitated group discussions. These included prioritising clinical care and newborn outcomes data, a parsimonious variable list, and electronic data entry. The tool was designed and refined by > 40 implementers and policymakers during a multi-stakeholder workshop and online interactions. RESULTS: Identified national and international datasets (n = 6) contained a median of 89 (IQR:61-154) variables, with many relating to research-specific initiatives. Maternal antenatal/intrapartum history was the largest variable category (21, 23.3%). The Neonatal Inpatient Dataset (NID) includes 60 core variables organised in six categories: (1) birth details/maternal history; (2) admission details/identifiers; (3) clinical complications/observations; (4) interventions/investigations; (5) discharge outcomes; and (6) diagnosis/cause-of-death. Categories were informed through the mapping process. The NID has been implemented at 69 neonatal units in four African countries and links to a facility-level quality improvement (QI) dashboard used in real-time by facility staff. CONCLUSION: The NEST360 NID is a novel, parsimonious tool for use in routine information systems to inform inpatient SSNC quality. Available on the NEST360/United Nations Children's Fund (UNICEF) Implementation Toolkit for SSNC, this adaptable tool enables facility and country-level comparisons to accelerate progress toward ENAP targets. Additional linked modules could include neonatal at-risk follow-up, retinopathy of prematurity, and Level-3 intensive care.

Digital Health Policy and Programs for Hospital Care in Vietnam: Scoping Review.

BACKGROUND: There are a host of emergent technologies with the potential to improve hospital care in low- and middle-income countries such as Vietnam. Wearable monitors and artificial intelligence-based decision support systems could be integrated with hospital-based digital health systems such as electronic health records (EHRs) to provide higher level care at a relatively low cost. However, the appropriate and sustainable application of these innovations in low- and middle-income countries requires an understanding of the local government's requirements and regulations such as technology specifications, cybersecurity, data-sharing protocols, and interoperability. OBJECTIVE: This scoping review aims to explore the current state of digital health research and the policies that govern the adoption of digital health systems in Vietnamese hospitals. METHODS: We conducted a scoping review using a modification of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. PubMed and Web of Science were searched for academic publications, and ThÆ° Vien Pháp Luat, a proprietary database of Vietnamese government documents, and the Vietnam Electronic Health Administration website were searched for government documents. Google Scholar and Google Search were used for snowballing searches. The sources were assessed against predefined eligibility criteria through title, abstract, and full-text screening. Relevant information from the included sources was charted and summarized. The review process was primarily undertaken by one researcher and reviewed by another researcher during each step. RESULTS: In total, 11 academic publications and 20 government documents were included in this review. Among the academic studies, 5 reported engineering solutions for information systems in hospitals, 2 assessed readiness for EHR implementation, 1 tested physicians' performance before and after using clinical decision support software, 1 reported a national laboratory information management system, and 2 reviewed the health system's capability to implement eHealth and artificial intelligence. Of the 20 government documents, 19 were promulgated from 2013 to 2020. These regulations and guidance cover a wide range of digital health domains, including hospital information management systems, general and interoperability standards, cybersecurity in health organizations, conditions for the provision of health information technology (HIT), electronic health insurance claims, laboratory information systems, HIT maturity, digital health strategies, electronic medical records, EHRs, and eHealth architectural frameworks. CONCLUSIONS: Research about hospital-based digital health systems in Vietnam is very limited, particularly implementation studies. Government regulations and guidance for HIT in health care organizations have been released with increasing frequency since 2013, targeting a variety of information systems such as electronic medical records, EHRs, and laboratory information systems. In general, these policies were focused on the basic specifications and standards that digital health systems need to meet. More research is needed in the future to guide the implementation of digital health care systems in the Vietnam hospital setting.

Mobile Health (mHealth) in Low- and Middle-Income Countries.

This article reflects on current trends and proposes new considerations for the future of mobile technologies for health (mHealth). Our focus is predominantly on the value of and concerns with regard to the application of digital health within low- and middle-income countries (LMICs). It is in LMICs and marginalized communities that mHealth (within the wider scope of digital health) could be most useful and valuable. Peer-reviewed literature on mHealth in LMICs provides reassurance of this potential, often reflecting on the ubiquity of mobile phones and ever-increasing connectivity globally, reaching remote or otherwise disengaged populations. Efforts to adapt successful programs for LMIC contexts and populations are only just starting to reap rewards. Private-sector investment in mHealth offers value through enhanced capacity and advances in technology as well as the ability to meet increasing consumer demand for real-time, accessible, convenient, and choice-driven health care options. We examine some of the potential considerations associated with a private-sector investment, questioning whether a core of transparency, local ownership, equity, and safety is likely to be upheld in the current environment of health entrepreneurship.

Data for tracking SDGs: challenges in capturing neonatal data from hospitals in Kenya.

Background: Target 3.2 of the United Nations Sustainable Development Goals (SDGs) is to reduce neonatal mortality. In low-income and middle-income countries (LMICs), the District Health Information Software, V.2 (DHIS2) is widely used to help improve indicator data reporting. There are few reports on its use for collecting neonatal hospital data that are of increasing importance as births within facilities increase. To address this gap, we investigated implementation experiences of DHIS2 in LMICs and mapped the information flow relevant for neonatal data reporting in Kenyan hospitals. Methods: A narrative review of published literature and policy documents from LMICs was conducted. Information gathered was used to identify the challenges around DHIS2 and to map information flows from healthcare facilities to the national level. Two use cases explore how newborn data collection and reporting happens in hospitals. The results were validated, adjusted and system challenges identified. Results: Literature and policy documents report that DHIS2 is a useful tool with strong technical capabilities, but significant challenges can emerge with the implementation. Visualisations of information flows highlight how a complex, people-based and paper-based subsystem for inpatient information capture precedes digitisation. Use cases point to major challenges in these subsystems in accurately identifying newborn deaths and appropriate data for the calculation of mortality even in hospitals. Conclusions: DHIS2 is a tool with potential to improve availability of health information that is key to health systems, but it critically depends on people-based and paper-based subsystems. In hospitals, the subsystems are subject to multiple micro level challenges. Work is needed to design and implement better standardised information processes, recording and reporting tools, and to strengthen the information system workforce. If the challenges are addressed and data quality improved, DHIS2 can support countries to track progress towards the SDG target of improving neonatal mortality.

I've got 99 problems but a phone ain't one: Electronic and mobile health in low and middle income countries.

Mobile technology is very prevalent in Kenya-mobile phone penetration is at 88% and mobile data subscriptions form 99% of all internet subscriptions. While there is great potential for such ubiquitous technology to revolutionise access and quality of healthcare in low-resource settings, there have been few successes at scale. Implementations of electronic health (e-Health) and mobile health (m-Health) technologies in countries like Kenya are yet to tackle human resource constraints or the political, ethical and financial considerations of such technologies. We outline recent innovations that could improve access and quality while considering the costs of healthcare. One is an attempt to create a scalable clinical decision support system by engaging a global network of specialist doctors and reversing some of the damaging effects of medical brain drain. The other efficiently extracts digital information from paper-based records using low-cost and locally produced tools such as rubber stamps to improve adherence to clinical practice guidelines. By bringing down the costs of remote consultations and clinical audit, respectively, these projects offer the potential for clinics in resource-limited settings to deliver high-quality care. This paper makes a case for continued and increased investment in social enterprises that bridge academia, public and private sectors to deliver sustainable and scalable e-Health and m-Health solutions.

Building Learning Health Systems to Accelerate Research and Improve Outcomes of Clinical Care in Low- and Middle-Income Countries.

Mike English and colleagues argue that as efforts are made towards achieving universal health coverage it is also important to build capacity to develop regionally relevant evidence to improve healthcare.

Creating connections - the development of a mobile-health monitoring system for heart failure: Qualitative findings from a usability cohort study.

OBJECTIVE: There is significant interest in the role of digital health technology in enabling optimal monitoring of heart failure patients. To harness this potential, it is vital to account for users' capacity and preferences in the development of technological solutions. We adopted an iterative approach focussed on learning from users' interactions with a mobile-health monitoring system. METHODS: We used a participatory mixed methods research approach to develop and evaluate a mobile-health monitoring system. Fifty-eight heart failure patients were recruited from three health care settings in the UK and provided with Internet-enabled tablet computers that were wirelessly linked to sensor devices for blood pressure, heart rate and weight monitoring. One to two home visits were conducted with a subgroup of 29 participants to evaluate the usability of the system over a median follow-up period of six months. The thematic analysis of observational data and 45 interviews was informed by the domestication of technology theory. RESULTS: Our findings indicate that digital health technologies need to create and extend connections with health professionals, be incorporated into users' daily routines, and be personalised according to users' technological competencies and interest in assuming a proactive or more passive role in monitoring their condition. CONCLUSIONS: Users' patterns of engagement with health technology changes over time and varies according to their need and capacity to use the technology. Incorporating diverse user experiences in the development and maintenance of mobile-health systems is likely to increase the extent of successful uptake and impacts on outcomes for patients and providers.

Use of interval based quality indicators in blood pressure management to enhance quality of pay for performance incentives: comparison to two indicators from the Quality and Outcomes Framework.

BACKGROUND: Pay for performance incentives are becoming increasingly popular, but are typically based on only a single point-in-time measurement as an indicator of chronic condition management. AIMS: To determine the association between three time-interval based indicators of suboptimal blood pressure (BP) control and two point-in-time indicators from the UK Quality and Outcomes Framework (QOF): BP5 (the percentage of patients with hypertension in whom the last BP in the previous nine months was < or = 150/90) and DM12 (the percentage of patients with diabetes in whom the last BP in the previous 15 months was < or = 145/85). METHODS: We extracted classification data and BP measurements from four New Zealand general practices with 4260 to 6130 enrolled patients. Data were analysed for three indicators with respect to a nine-month evaluation period for patients with hypertension and a 15-month period for patients with diabetes: (1) two or more consistently high BP measurements spaced over > or = 90 days, (2) a high BP measurement followed by a lapse of >120 days in BP measurement and (3) no BP measurement for >180 days. RESULTS: For the four practices, 65-81% of the patients satisfied BP5 and 59-68% of patients satisfied DM12. Of the hypertension patients satisfying BP5, 31% (95% CI: 28-33%) failed at least one of the three interval based indicators; 42% (95% CI: 39-46%) of the diabetes patients satisfying DM12 failed at least one of the three interval based indicators. CONCLUSION: Considering only a point-in-time controlled BP measurement provides an incomplete view of the quality of BP management in patients with hypertension or diabetes over a period of time.