Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya.

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.

Expectations for nursing care in newborn units in Kenya: moving from implicit to explicit standards.

Neonatal mortality currently accounts for 45% of all child mortality in Kenya, standing at 22 per 1000 live births. Access to basic but high quality inpatient neonatal services for small and sick newborns will be key in reducing neonatal mortality. Neonatal inpatient care is reliant on nursing care, yet explicit nursing standards for such care do not currently exist in Kenya. We reviewed the Nursing Council of Kenya 'Manual of Clinical Procedures' to identify tasks relevant for the care of inpatient neonates. An expert advisory group comprising major stakeholders, policy-makers, trainers, and frontline health-workers was invited to a workshop with the purpose of defining tasks for which nurses are responsible and the minimum standard with which these tasks should be delivered to inpatient neonates in Kenyan hospitals. Despite differences in opinions at the beginning of the process, consensus was reached on the minimum standards of neonatal nursing. The key outcome was a comprehensive list and grouping of neonatal nursing task and the minimum frequency with which these tasks should be performed. Second, a simple categorisation of neonatal patients based on care needs was agreed. In addition, acceptable forms of task sharing with other cadres and the patient's family for the neonatal nursing tasks were agreed and described. The process was found to be acceptable to policy-makers and practitioners, who recognised the value of standards in neonatal nursing to improve the quality of neonatal inpatient care. Such standards could form the basis for audit and quality evaluation.