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First referral hospitals (FRHs) are the hospitals closest to the community, which offer expertise or technologies to complement more widely available 'basic' ambulatory care or inpatient care. Despite having been a subject of interest in global health policy in the latter half of the 20th century, in more recent decades, they appear to have been overshadowed. This paper reviews what is understood by FRH, drawing on both academic and policy literature, complemented by specific country case studies. We undertook three reviews: a grey literature review of global and regional policy reports and documents, a structured review of the academic literature on FRH and a review of FRH-related policies in eight countries. Our findings indicate that there is confusion regarding the definitions and roles of FRH; they have fallen off the policy agenda globally and they suffer from lack of advocates in part related to the absence of cohesive definition. Meanwhile, these facilities continue to fulfil important functions in health systems in low- and middle-income countries, and expectations for service delivery remain high. In light of these findings, this paper calls for renewed interest and investment in FRH from the global health academic and policy-making community. [ABSTRACT FROM AUTHOR]

Impact of a multifaceted intervention to improve emergency care on newborn and child health outcomes in Rwanda. Some trials of service delivery interventions have demonstrated effects on hospital mortality in LRS, but these have employed randomization at the individual level and well-resourced, sustained and trial-supported change efforts ([2]; [16]). Keywords: Implementation; quality of care; study design; complexity EN Implementation quality of care study design complexity 808 810 3 06/15/22 20220601 NES 220601 Key messages Strategies to provide emergency care training and promote use of clinical guidelines targeting common severe illness in newborns and children are available but there remain few studies testing the consequences of introducing these through multifaceted interventions. Improving emergency and admission care in low-resource, high mortality hospital settings - not as easy as A, B and C. [Extracted from the article]

Background The malaria prevalence has declined in western Kenya, resulting in the risk of neurological phenotypes in older children. This study investigates the clinical profile of pediatric malaria admissions ahead of the introduction of the RTS,S/AS01 vaccine. Methods Malaria admissions in children aged 1 month to 15 years were identified from routine, standardized, inpatient clinical surveillance data collected between 2015 and 2018 from 4 hospitals in western Kenya. Malaria phenotypes were defined based on available data. Results There were 5766 malaria admissions documented. The median age was 36 months (interquartile range, 18–60): 15% were aged between 1–11 months of age, 33% were aged 1–23 months of age, and 70% were aged 1 month to 5 years. At admission, 2340 (40.6%) children had severe malaria: 421/2208 (19.1%) had impaired consciousness, 665/2240 (29.7%) had an inability to drink or breastfeed, 317/2340 (13.6%) had experienced 2 or more convulsions, 1057/2340 (45.2%) had severe anemia, and 441/2239 (19.7%) had severe respiratory distress. Overall, 211 (3.7%) children admitted with malaria died; 163/211 (77% deaths, case fatality rate 7.0%) and 48/211 (23% deaths, case fatality rate 1.4%) met the criteria for severe malaria and nonsevere malaria at admission, respectively. The median age for fatal cases was 33 months (interquartile range, 12–72) and the case fatality rate was highest in those unconscious (44.4%). Conclusions Severe malaria in western Kenya is still predominantly seen among the younger pediatric age group and current interventions targeted for those <5 years are appropriate. However, there are increasing numbers of children older than 5 years admitted with malaria, and ongoing hospital surveillance would identify when interventions should target older children. [ABSTRACT FROM AUTHOR]

Background The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000 with the goal of eliminating lymphatic filariasis (LF) as a public health problem by 2020. Despite considerable progress, the current prevalence is around 60% of the 2000 figure, with the deadline looming a year away. Consequently, there is a continued need for investment in both the mass drug administration (MDA) and morbidity management programs, and this paper aims to demonstrate that need by estimating the health and economic burdens of LF prior to MDA programs starting in GPELF areas. Methods A previously developed model was used to estimate the numbers of individuals infected and individuals with symptomatic disease, along with the attributable number of disability-adjusted life years (DALYs). The economic burden was calculated by quantifying the costs incurred by the health-care system in managing clinical cases, the patients' out-of-pocket costs, and their productivity costs. Results Prior to the MDA program, approximately 129 million people were infected with LF, of which 43 million had clinical disease, corresponding to a DALY burden of 5.25 million. The average annual economic burden per chronic case was US $115, the majority of which resulted from productivity costs. The total economic burden of LF was estimated at US $5.8 billion annually. Conclusions These results demonstrate the magnitude of the LF burden and highlight the continued need to support the GPELF. Patients with clinical disease bore the majority of the economic burden, but will not benefit much from the current MDA program, which is aimed at reducing transmission. This assessment further highlights the need to scale up morbidity management programs. [ABSTRACT FROM AUTHOR]

An audit of randomly selected case records of 810 patients admitted to 13 hospitals between December 2015 and November 2016 was done. Prevalence of dehydration was 19.7% (2293 of 11 636) [95% CI: 17.1-22.6%], range across hospitals was 9.4% to 27.0%. Most cases with dehydration were clinically diagnosed (82 of 153; 53.6%), followed by excessive weight loss (54 of 153; 35.3%) and abnormal urea/electrolytes/creatinine (23 of 153; 15.0%). Documentation of fluids prescribed was poor but, where data were available, Ringers lactate (30 of 153; 19.6%) and 10% dextrose (18 of 153; 11.8%) were mostly used. Only 17 of 153 (11.1%) children had bolus fluid prescription, and Ringer's lactate was most commonly used for bolus at a median volume per kilogram body weight of 20 ml/kg (interquartile range, 12-30 ml/kg). Neonatal dehydration is common, but current documentation may underestimate the burden. Heterogeneity in practice likely reflects the absence of guidelines that in turn reflects a lack of research informing practical treatment guidelines. [ABSTRACT FROM AUTHOR]

Clinical leadership is recognized as a crucial element in health system strengthening and health policy globally yet it has received relatively little attention in low and middle income countries (LMICs). Moreover, analyses of clinical leadership tend to focus on senior-level individual leaders, overlooking a wider constellation of middle-level leaders delivering health care in practice in a way affected by their health care context. Using the theoretical lens of 'distributed leadership', this article examines how middle-level leadership is practised and affected by context in Kenyan county hospitals, providing insights relevant to health care in other LMICs. The article is based on empirical qualitative case studies of clinical departmental leadership in two Kenyan public hospitals, drawing on data gathered through ethnographic observation, interviews and focus groups. We inductively and iteratively coded, analysed and theorized our findings. We found the distributed leadership lens useful for the purpose of analysing middle-level leadership in Kenyan hospitals, although clinical departmental leadership was understood locally in more individualized terms. Our distributed lens revealed medical and nursing leadership occurring in parallel and how only doctors in leadership roles were able to directly influence behaviour among their medical colleagues, using inter-personal skills, power and professional expertize. Finally, we found that Kenyan hospital contexts were characterized by cultures, norms and structures that constrained the way leadership was practiced. We make a theoretical contribution by demonstrating the utility of using distributed leadership as a lens for analysing leadership in LIMC health care contexts, revealing how context, power and inter-professional relationships moderate individual leaders' ability to bring about change. Our findings, have important implications for how leadership is conceptualized and the way leadership development and training are provided in LMICs health systems. [ABSTRACT FROM AUTHOR]

This paper describes and evaluates the budgeting and planning processes in public hospitals in Kenya. We used a qualitative case study approach to examine these processes in two hospitals in Kenya. We collected data by in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), a review of documents, and non-participant observations within the hospitals over a 7 month period. We applied an evaluative framework that considers both consequentialist and proceduralist conditions as important to the quality of priority-setting processes. The budgeting and planning process in the case study hospitals was characterized by lack of alignment, inadequate role clarity and the use of informal priority-setting criteria. With regard to consequentialist conditions, the hospitals incorporated economic criteria by considering the affordability of alternatives, but rarely considered the equity of allocative decisions. In the first hospital, stakeholders were aware of - and somewhat satisfied with - the budgeting and planning process, while in the second hospital they were not. Decision making in both hospitals did not result in reallocation of resources. With regard to proceduralist conditions, the budgeting and planning process in the first hospital was more inclusive and transparent, with the stakeholders more empowered compared to the second hospital. In both hospitals, decisions were not based on evidence, implementation of decisions was poor and the community was not included. There were no mechanisms for appeals or to ensure that the proceduralist conditions were met in both hospitals. Public hospitals in Kenya could improve their budgeting and planning processes by harmonizing these processes, improving role clarity, using explicit priority-setting criteria, and by incorporating both consequentialist (efficiency, equity, stakeholder satisfaction and understanding, shifted priorities, implementation of decisions), and proceduralist (stakeholder engagement and empowerment, transparency, use of evidence, revisions, enforcement, and incorporating community values) conditions. [ABSTRACT FROM AUTHOR]

Objective: To share approaches and innovations adopted to deliver a relatively inexpensive clinical data management (CDM) framework within a low-income setting that aims to deliver quality pediatric data useful for supporting research, strengthening the information culture and informing improvement efforts in local clinical practice.Materials and Methods: The authors implemented a CDM framework to support a Clinical Information Network (CIN) using Research Electronic Data Capture (REDCap), a noncommercial software solution designed for rapid development and deployment of electronic data capture tools. It was used for collection of standardized data from case records of multiple hospitals' pediatric wards. R, an open-source statistical language, was used for data quality enhancement, analysis, and report generation for the hospitals.Results: In the first year of CIN, the authors have developed innovative solutions to support the implementation of a secure, rapid pediatric data collection system spanning 14 hospital sites with stringent data quality checks. Data have been collated on over 37 000 admission episodes, with considerable improvement in clinical documentation of admissions observed. Using meta-programming techniques in R, coupled with branching logic, randomization, data lookup, and Application Programming Interface (API) features offered by REDCap, CDM tasks were configured and automated to ensure quality data was delivered for clinical improvement and research use.Conclusion: A low-cost clinically focused but geographically dispersed quality CDM (Clinical Data Management) in a long-term, multi-site, and real world context can be achieved and sustained and challenges can be overcome through thoughtful design and implementation of open-source tools for handling data and supporting research. [ABSTRACT FROM AUTHOR]

A cross-sectional survey was conducted in neonatal and maternity units of five Kenyan district public hospitals. Data for 1 year were obtained: 3999 maternal and 1836 neonatal records plus tallies of maternal deaths, deliveries and stillbirths. There were 40 maternal deaths [maternal mortality ratio: 276 per 100 000 live births, 95% confidence interval (CI): 197-376]. Fresh stillbirths ranged from 11 to 43 per 1000 births. A fifth (19%, 263 of 1384, 95% CI: 11-30%) of the admitted neonates died. Compared with normal birth weight, odds of death were significantly higher in all of the low birth weight (LBW, <2500 g) categories, with the highest odds for the extremely LBW (<1000 g) category (odds ratio: 59, 95% CI: 21-158, p < 0.01). The observed maternal mortality, stillbirths and neonatal mortality call for implementation of the continuum of care approach to intervention delivery with particular emphasis on LBW babies. [ABSTRACT FROM AUTHOR]

Background. There are concerns that the evidence from studies showing noninferiority of oral amoxicillin to benzyl penicillin for severe pneumonia may not be generalizable to high-mortality settings. Methods. An open-label, multicenter, randomized controlled noninferiority trial was conducted at 6 Kenyan hospitals. Eligible children aged 2-59 months were randomized to receive amoxicillin or benzyl penicillin and followed up for the primary outcome of treatment failure at 48 hours. A noninferiority margin of risk difference between amoxicillin and benzyl penicillin groups was prespecified at 7%. Results. We recruited 527 children, including 302 (57.3%) with comorbidity. Treatment failure was observed in 20 of 260 (7.7%) and 21 of 261 (8.0%) of patients in the amoxicillin and benzyl penicillin arms, respectively (risk difference, -0.3% [95% confidence interval, -5.0% to 4.3%]) in per-protocol analyses. These findings were supported by the results of intention-to-treat analyses. Treatment failure by day 5 postenrollment was 11.4% and 11.0% and rising to 13.5% and 16.8% by day 14 in the amoxicillin vs benzyl penicillin groups, respectively. The most frequent cause of cumulative treatment failure at day 14 was clinical deterioration within 48 hours of enrollment (33/59 [55.9%]). Four patients died (overall mortality 0.8%) during the study, 3 of whom were allocated to the benzyl penicillin group. The presence of wheeze was independently associated with less frequent treatment failure. Conclusions. Our findings confirm noninferiority of amoxicillin to benzyl penicillin, provide estimates of risk of treatment failure in Kenya, and offer important additional evidence for policy making in sub-Saharan Africa. Clinical Trial Registration. NCT01399723 [ABSTRACT FROM AUTHOR]

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Globally, pneumonia is the leading cause of death in children <5 years of age. Hypoxemia, a frequent complication of pneumonia, is a risk factor for death. To better understand the availability of oxygen and pulse oximetry, barriers to use and provider perceptions and practices regarding their role in childhood pneumonia, we conducted a survey using a convenience sampling strategy targeting clinicians working in resource-limited countries. Most respondents were physicians from public district and provincial hospitals with access to oxygen and pulse oximetry; however, reported therapeutic use for childhood pneumonia was low. Common barriers included insufficient supply, competition for use, lack of policies, guidelines and training and perceived high cost. Despite the frequency of hypoxemia, the inaccuracy of clinical predictors, the poor outcome hypoxemia portends and the effectiveness of pulse oximetry and oxygen in childhood pneumonia, our data indicate that these tools may be underused in resource-limited settings. [ABSTRACT FROM PUBLISHER]

Abstract: Bridging the gap between research evidence and practice is problematic in low income settings. We report medical students’ experience with a pilot computer aided learning (CAL) program developed to enable students to explore research evidence supporting national guidelines. We asked 50 students to enter data from pre-set clinical scenarios, diagnose the severity of pneumonia/asthma and suggest treatment and then compare their diagnosis and treatment with that suggested by a computer algorithm based on the guidelines. Links to evidence supporting the guideline-suggested diagnosis and treatment were provided. Brief evidence summaries and video clips were accessed by 92% of students and full text articles by 86%. The majority of the students showed an interest in the CAL approach and suggested the scope of the approach be expanded to other illnesses. Such a system might provide one means to help students understand the link between research and policy and ultimately influence practice. [Copyright &y& Elsevier]

Hypoglycaemia is associated with poor prognosis in many severe childhood illnesses especially in sub-Saharan Africa where the prevalence of malaria, diarrhoea and malnutrition remains high. Uncertainty, however, still persists regarding the significance, definition and management of childhood hypoglycaemia. As a step towards defining optimal, evidence-based diagnostic and management criteria, we (i) reviewed the evidence underlying current recommendations for the management of hypoglycaemia, and (ii) analysed a large set of data on blood glucose levels and associated outcomes of paediatric admissions in a rural hospital over an 11-year period. Current definitions and treatment protocols for hypoglycaemia are based on observational data and expert opinion. Future large pragmatic randomized trials would help define optimal treatment thresholds. Emerging evidence suggests that sublingual sugar is a feasible and effective therapy for correction of hypoglycaemia, and should be considered where intravenous glucose is delayed or impossible. [ABSTRACT FROM PUBLISHER]

Summary: Considerable uncertainty persists regarding the efficacy and safety of methylxanthines (caffeine, theophylline – in intravenous form named aminophylline) for the prevention and treatment of infant apnea. To help inform national guideline development in Kenya we undertook structured literature searches to identify current evidence on caffeine therapy for infant apnea. Available evidence shows that caffeine is as effective as intravenous theophylline (aminophylline), but is safer and easier to give and has better therapeutic properties. It is therefore recommended for the treatment of apnea of prematurity. Caffeine is also the preferred drug if clinicians plan to provide apnea prophylaxis. As prematurity is likely to result in more than 1 million deaths a year, mostly in resource-poor settings, greater efforts need to be made to ensure interventions such as caffeine, currently unavailable in countries such as Kenya, are made more widely available. [Copyright &y& Elsevier]

Background. Although necessary for developing a rationale for vaccination, the burden of severe respiratory syncytial virus (RSV) disease in children in resource-poor settings remains poorly defined. Methods. We conducted prospective surveillance of severe and very severe pneumonia in children aged <5 years admitted from 2002 through 2007 to Kilifi district hospital in coastal Kenya. Nasal specimens were screened for RSV antigen by immunofluorescence. Incidence rates were estimated for the well-defined population. Results. Of 25,149 hospital admissions, 7359 patients (29%) had severe or very severe pneumonia, of whom 6026 (82%) were enrolled. RSV prevalence was 15% (20% among infants) and 27% during epidemics (32% among infants). The proportion of case patients aged ⩾3 months was 65%, and the proportion aged ⩾6 months was 43%. Average annual hospitalization rates were 293 hospitalizations per 100,000 children aged <5 years (95% confidence interval, 271-371 hospitalizations per 100,000 children aged <5 years) and 1107 hospitalizations per 100,000 infants (95% confidence interval, 1012-1211 hospitalizations per 100,000 infants). Hospital admission rates were double in the region close to the hospital. Few patients with RSV infection had life-threatening clinical features or concurrent serious illnesses, and the associated mortality was 2.2%. Conclusions. In this low-income setting, rates of hospital admission with RSV-associated pneumonia are substantial; they are comparable to estimates from the United States but considerably underestimate the burden in the full community. An effective vaccine for children aged >2 months (outside the age group of poor responders) could prevent a large portion of RSV disease. Severity data suggest that the justification for RSV vaccination will be based on the prevention of morbidity, not mortality. [ABSTRACT FROM AUTHOR]

Summary: We conducted a prospective audit of 101 children aged 6 to 59 months, admitted to Kenyatta National Hospital (KNH) with severe malnutrition, from February-April 2008. Forty-seven per cent (47/101) of children were younger than one year old. Overall, 58% (59/101) of children had marasmus, 70.3% (71/101) had diarrhoea and 51.5% (52/101) had pneumonia on admission. A structured tool was prepared to capture data to allow assessment of implementation of WHO guidelines steps 1–8. The highest degree of implementation (91/101, 90%) was observed for Step 5: treatment of potentially severe infections, although only 55% (56/101) of patients had F75 prescribed even though this starter formula was available. There was modest implementation of Step 2: ensuring warmth (47/101, 46.5%), Step 3: treatment of dehydration (39/71, 54.9%) and Step 4: correction of electrolyte imbalance (46/101, 45.5%). There was least implementation of Step 8: transition to catch-up feeding (16/67, 23.8%). There was a delay in initiating feeds with a median time of 14.7hours from the time of admission. We conclude that quality of care for children admitted with severe malnutrition at KNH, Kenya''s largest tertiary level health facility, is inadequate and often does not follow WHO guidelines. Improving care will require a holistic and not simply medical approach. [Copyright &y& Elsevier]

Background. Human immunodeficiency virus (HIV) infection, malnutrition, and invasive bacterial infection (IBI) are reported among children with severe malaria. However, it is unclear whether their cooccurrence with falciparum parasitization and severe disease happens by chance or by association among children in areas where malaria is endemic. Methods. We examined 3068 consecutive children admitted to a Kenyan district hospital with clinical features of severe malaria and 592 control subjects from the community. We performed multivariable regression analysis, with each case weighted for its probability of being due to falciparum malaria, using estimates of the fraction of severe disease attributable to malaria at different parasite densities derived from cross-sectional parasitological surveys of healthy children from the same community. Results. HIV infection was present in 133 (12%) of 1071 consecutive parasitemic admitted children (95% confidence interval [CI], 11%-15%). Parasite densities were higher in HIV-infected children. The odds ratio for admission associated with HIV infection for admission with true severe falciparum malaria was 9.6 (95% CI, 4.9- 19); however, this effect was restricted to children aged ⩾1 year. Malnutrition was present in 507 (25%) of 2048 consecutive parasitemic admitted children (95% CI, 23%-27%). The odd ratio associated with malnutrition for admission with true severe falciparum malaria was 4.0 (95% CI, 2.9-5.5). IBI was detected in 127 (6%) of 2048 consecutive parasitemic admitted children (95% CI, 5.2%-7.3%). All 3 comorbidities were associated with increased case fatality. Conclusions. HIV, malnutrition and IBI are biologically associated with severe disease due to falciparummalaria rather than being simply alternative diagnoses in co-incidentally parasitized children in an endemic area. [ABSTRACT FROM AUTHOR]

In a region with high rates of mortality among children aged <5 years, the under funded health care systems of sub-Saharan Africa have few resources available to perform surveillance activities that can help determine the causes of morbidity and mortality in the region. At present, there are few examples of attempts to promote public health care surveillance that might inform current debates about how to expand and improve surveillance, particularly for bacterial diseases. Driven by this gap in knowledge, we attempted to explore the successes and failures of the Network for Surveillance of Pneumococcal Disease in the East African Region and to share the experiences of what are essentially non-research public-sector hospitals in East Africa, with the hopes that surveillance systems for other diseases, especially those that require complex diagnostic support, may be informed by these experiences. The state of services essential for surveillance and the measures taken to overcome any shortcomings are described, as is the progress made in improving clinical diagnosis, laboratory processing, and data management. For surveillance to play a role in public health care, ministries of health and associated institutions must own and push forward the surveillance agenda, with support from global partners, and take advantage of the developments that have been achieved within the institutions. [ABSTRACT FROM AUTHOR]

Summary: Globally, young infant mortality comprises 40% of the estimated 10.8million child deaths annually. Almost all (99%) of these deaths arise in low- and middle-income countries (LMICs). Achievement of the Millennium Development Goal for child survival, however, requires a significant improvement in the management of infections in young infants. We have reviewed current evidence from LMICs on one major cause of young infant mortality, severe infection, and have described the range of pathogens, reported antibiotic susceptibility and value of clinical signs in identifying severe bacterial illness. Evidence from the reviewed studies appears to show that common pathogens in young infant infections change over time and vary within and across settings. However, there are few good, large studies outside major urban settings and many reports describe infections of babies born in hospital when most young infant infections probably occur in the majority born at home. Yet what knowledge there is can aid in instituting prompt and appropriate therapy, and perhaps thus minimize the emergence of multidrug-resistant bacteraemia, a major threat at least in hospital settings. Improved country level data on pattern of microorganisms, resistance and antibiotic use are required to help reduce mortality through development of local, evidence-based clinical guidelines. [Copyright &y& Elsevier]

Summary: Current resuscitation practices are often poor in low-income settings. The purpose of this review was to summarise recent evidence, relevant to developing countries, on best practice in the provision of newborn resuscitation. Potential studies for inclusion were identified using structured searches of MEDLINE via PubMed. Two reviewers independently evaluated retrieved studies for inclusion. The methodological quality of the selected articles was assessed using the Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence, whilst the Scottish Intercollegiate Guidelines Network (SIGN) grading system was used for subsequent recommendations. Based on available evidence, where there is meconium-stained liquor, routine perineal suction of all babies and endotracheal suction of active babies do not prevent meconium aspiration syndrome and have potential risks. Adequate ventilation is possible with a bag-valve-mask device and room air is just as efficient as oxygen for initial resuscitation. This review supports the view that effective resuscitation is possible with basic equipment and minimal skills. Thus, where resources are limited, it should be possible to improve neonatal outcomes through promotion of the effective use of a bag-valve-mask alone, without access to more sophisticated and expensive technologies. Basic, effective resuscitation should therefore be available at all health facilities and potentially in the community. [Copyright &y& Elsevier]