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Introduction: Information on laboratory test availability and current testing scope among general hospitals in Kenya is not readily available. We sought to explore the reporting trends and test availability within clinical laboratories in Kenya over a 24-months period through analysis of the laboratory data reported in the District Health Information System (DHIS2). Methods: Monthly hospital laboratory testing data were extracted from the Kenyan DHIS2 between January 2018 and December 2019. We used the national laboratory testing summary tool (MoH 706) to identify the tests of interest among 204 general hospitals in Kenya. A local practitioner panel consisting of individuals with laboratory expertise was used to classify the tests as common and uncommon. We compared the tests on the MoH 706 template with the Essential Diagnostic List (EDL) of the World Health Organisation and further reclassified them into test categories based on the EDL for generalisability of our findings. Evaluation of the number of monthly test types reported in each facility and the largest number of tests ever reported in any of the 24 months were used to assess test availability and testing scope, respectively. Results: Out of the 204 general hospitals assessed, 179 (179/204) reported at least one of the 80 tests of interest in any of the 24 months. Only 41% (74/179) of the reporting hospitals submitted all their monthly DHIS2 laboratory reports for the entire 24 months. The median testing capacity across the hospitals was 40% with a wide variation in testing scope from one hospital laboratory to another (% IQR: 33.8–51.9). Testing scope was inconsistent within facilities as indicated by often large monthly fluctuations in the total number of recommended and EDL tests reported. Tests of anatomical pathology and cancer were the least reported with 4 counties' hospitals not reporting any cancer or anatomical pathology tests for the entire 24 months. Conclusion: The current reporting of laboratory testing information in DHIS2 is poor. Monitoring access and utilisation of laboratory testing across the country would require significant improvements in consistency and coverage of routine laboratory test reporting in DHIS2. Nonetheless, the available data suggest unequal and intermittent population access to laboratory testing provided by general hospitals in Kenya. [ABSTRACT FROM AUTHOR]

Others have made the point convincingly that Millennium Development Goal 4, a reinvigorated commitment to reduce child mortality by two-thirds before 2015, could be achieved if existing interventions were implemented [...]

Pneumonia is the single commonest cause of death Pin children under five years old, accounting for 2 million out of 10 million childhood deaths worldwide [1]. Severe pneumonia is an [...]

ABSTRACT Background Clinical trials of interventions designed to prevent severe falciparum malaria in children require a clear endpoint. The internationally accepted definition of severe malaria is sensitive, and appropriate for [...]

Author(s): Mike English 1,2,*, Grace Irimu 2,3, Ambrose Agweyu 2, David Gathara 2, Jacquie Oliwa 2, Philip Ayieko 2, Fred Were 4, Chris Paton 1, Sean Tunis 5, Christopher B. [...]

Summary Points * Antibiotics that are well absorbed after oral administration are available, and the best current evidence suggests they are safe and effective for many conditions. * Belief in the superiority of intravenous antibiotics is widespread among health professionals and patients, but it is not supported by good evidence. Expanding the evidence base will provide patients and clinicians with further reassurance in specific situations, but reasons for the belief in the strength of intravenous therapy also need to be understood and addressed. * Trials expanding the evidence base might follow noninferiority designs, based on the precedent of widespread intravenous use. For many indications, the theoretical reasons for preferring intravenous therapy are not strong, and the risks of intravenous therapy are well established. It would be more logical for many indications to regard oral antibiotics as the default position and require trial designs to test the superiority of intravenous therapy. * Clarity regarding the harms and benefits of intravenous antibiotics is needed. There is potential to change global clinical practice for the better, reducing health care costs and minimizing harm to patients., Intravenous Antibiotic Use Antibiotics given intravenously are commonly used in both high- and low-income countries. Available evidence from well-established antibiotic stewardship programmes in high-income settings suggests this is frequently unnecessary [...]

Background to the debate: Current guidelines recommend that all fever episodes in African children be treated presumptively with antimalarial drugs. But declining malarial transmission in parts of sub-Saharan Africa, declining proportions of fevers due to malaria, and the availability of rapid diagnostic tests mean it may be time for this policy to change. This debate examines whether enough evidence exists to support abandoning presumptive treatment and whether African health systems have the capacity to support a shift toward laboratory-confirmed rather than presumptive diagnosis and treatment of malaria in children under five., In this Viewpoint, Mike English and colleagues argue against abandoning presumptive treatment for under-fives. Blaise Genton and colleagues present the opposing Viewpoint in a related article: D'Acremont V, Lengeler C, [...]

Background: Poor water sanitation and hygiene (WASH) in health care facilities increases hospital-associated infections, and the resulting greater use of second-line antibiotics drives antimicrobial resistance. Recognising the existing gaps, the World Health Organisations' Water and Sanitation for Health Facility Improvement Tool (WASH-FIT) was designed for self-assessment. The tool was designed for small primary care facilities mainly providing outpatient and limited inpatient care and was not designed to compare hospital performance. Together with technical experts, we worked to adapt the tool for use in larger facilities with multiple inpatient units (wards), allowing for comparison between facilities and prompt action at different levels of the health system. Methods: We adapted the existing facility improvement tool (WASH-FIT) to create a simple numeric scoring approach. This is to illustrate the variation across hospitals and to facilitate monitoring of progress over time and to group indicators that can be used to identify this variation. Working with stakeholders, we identified those responsible for action to improve WASH at different levels of the health system and used piloting, analysis of interview data to establish the feasibility and potential value of the WASH Facility Survey Tool (WASH-FAST) to demonstrate such variability. Results: We present an aggregate percentage score based on 65 indicators at the facility level to summarise hospitals' overall WASH status and how this varies. Thirty-four of the 65 indicators spanning four WASH domains can be assessed at ward level enabling within hospital variations to be highlighted. Three levels of responsibility for WASH service monitoring and improvement were identified with stakeholders: the county/regional level, senior hospital management and hospital infection prevention and control committees. Conclusion: We propose WASH-FAST can be used as a survey tool to assess, measure and monitor the progress of WASH in hospitals in resource-limited settings, providing useful data for decision making and tracking improvements over time. [ABSTRACT FROM AUTHOR]

Background: Water Sanitation and Hygiene (WASH) in healthcare facilities is critical in the provision of safe and quality care. Poor WASH increases hospital-associated infections and contributes to the rise of antimicrobial resistance (AMR). It is therefore essential for governments and hospital managers to know the state of WASH in these facilities to set priorities and allocate resources. Methods: Using a recently developed survey tool and scoring approach, we assessed WASH across four domains in 14 public hospitals in Kenya (65 indicators) with specific assessments of individual wards (34 indicators). Aggregate scores were generated for whole facilities and individual wards and used to illustrate performance variation and link findings to specific levels of health system accountability. To help interpret and contextualise these scores, we used data from key informant interviews with hospital managers and health workers. Results: Aggregate hospital performance ranged between 47 and 71% with five of the 14 hospitals scoring below 60%. A total of 116 wards were assessed within these facilities. Linked to specific domains, ward scores varied within and across hospitals and ranged between 20% and 80%. At ward level, some critical indicators, which affect AMR like proper waste segregation and hand hygiene compliance activities had pooled aggregate scores of 45 and 35% respectively. From 31 interviews conducted, the main themes that explained this heterogenous performance across facilities and wards included differences in the built environment, resource availability, leadership and the degree to which local managers used innovative approaches to cope with shortages. Conclusion: Significant differences and challenges exist in the state of WASH within and across hospitals. Whereas the senior hospital management can make some improvements, input and support from the national and regional governments are essential to improve WASH as a basic foundation for averting nosocomial infections and the spread of AMR as part of safe, quality hospital care in Kenya. [ABSTRACT FROM AUTHOR]

Background: True burden of tuberculosis (TB) in children is unknown. Hospitalised children are low-hanging fruit for TB case detection as they are within the system. We aimed to explore the process of recognition and investigation for childhood TB using a guideline-linked cascade of care. Methods: This was an observational study of 42,107 children admitted to 13 county hospitals in Kenya from 01Nov 15-31Oct 16, and 01Nov 17-31Oct 18. We estimated those that met each step of the cascade, those with an apparent (or “Working”) TB diagnosis and modelled associations with TB tests amongst guideline-eligible children. Results: 23,741/42,107 (56.4%) met step 1 of the cascade (≥2 signs and symptoms suggestive of TB). Step 2(further screening of history of TB contact/full respiratory exam) was documented in 14,873/23,741 (62.6%) who met Step 1. Step 3(chest x-ray or Mantoux test) was requested in 2,451/14,873 (16.5%) who met Step 2. Step 4(≥1 bacteriological test) was requested in 392/2,451 (15.9%) who met Step 3. Step 5(“Working TB” diagnosis) was documented in 175/392 (44.6%) who met Step 4. Factors associated with request of TB tests in patients who met Step 1 included: i) older children [AOR 1.19(CI 1.09–1.31)]; ii) co-morbidities of HIV, malnutrition or pneumonia [AOR 3.81(CI 3.05–4.75), 2.98(CI 2.69–3.31) and 2.98(CI 2.60–3.40) respectively]; iii) sicker children, readmitted/referred [AOR 1.24(CI 1.08–1.42) and 1.15(CI 1.04–1.28) respectively]. “Working TB” diagnosis was made in 2.9%(1,202/42,107) of all admissions and 0.2%(89/42,107) were bacteriologically-confirmed. Conclusions: More than half of all paediatric admissions had symptoms associated with TB and nearly two-thirds had more specific history documented. Only a few amongst them got TB tests requested. TB was diagnosed in 2.9% of all admissions but most were inadequately investigated. Major challenges remain in identifying and investigating TB in children in hospitals with access to Xpert MTB/RIF and a review is needed of existing guidelines. [ABSTRACT FROM AUTHOR]

Background: To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale. Methods and Findings: Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26-67.06) in intervention hospitals compared to US$31.1 (95% CI 30.6747.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19-2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A 'what-if' analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3. Conclusion: Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions. Please see later in the article for the Editors' Summary., Introduction An estimated 7.6 million children die globally every year before the age of five [1]. 99% of these deaths occur in developing countries; 50% in sub-Saharan Africa [2]. Most [...]

Background: In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated. Methods and Findings: This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n = 4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n = 4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline. In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean = 0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05-0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%;17.1% [8.04%-26.1%]);loading dose quinine (91.9% versus 66.7%, 26.3% [-3.66% to 56.3%]);and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%;29.9% [10.9%-48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose >40 mg/ kg/day;1.0% versus 7.5%;-6.5% [-12.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%;-6.8% [-11.9% to -1.6%]). Conclusions: Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings. Trial registration: Current Controlled Trials ISRCTN42996612 Please see later in the article for the Editors' Summary., Introduction Common illnesses including pneumonia, malaria, and diarrhea remain major contributors to child mortality in low-income countries [1]. Hospital care of severe illnesses may help improve survival, and disease-specific clinical [...]

Sepsis is a life-threatening dysfunction of the immune system leading to multiorgan failure that is precipitated by infectious diseases and is a leading cause of death in children under 5 years of age. It is necessary to be able to identify a sick child at risk of developing sepsis at the earliest point of presentation to a healthcare facility so that appropriate care can be provided as soon as possible. Our study objective was to generate a list of consensus-driven predictor variables for the derivation of a prediction model that will be incorporated into a mobile device and operated by low-skilled healthcare workers at triage. By conducting a systematic literature review and examination of global guideline documents, a list of 72 initial candidate predictor variables was generated. A two-round modified Delphi process involving 26 experts from both resource-rich and resource-limited settings, who were also encouraged to suggest new variables, yielded a final list of 45 predictor variables after evaluating each variable based on three domains: predictive potential, measurement reliability, and level of training and resources required. The final list of predictor variables will be used to collect data and contribute to the derivation of a prediction model. [ABSTRACT FROM AUTHOR]

Background: Severe acute malnutrition (SAM) remains a major cause of admission and inpatient mortality worldwide in children aged less than 5 years. In this study, we explored SAM prevalence and outcomes in children admitted in 13 Kenyan hospitals participating in a Clinical Information Network (CIN). We also describe their immediate in-patient management. Methods: We analyzed data for children aged 1–59 months collected retrospectively from medical records after discharge. Mean, median and ranges were used to summarize pooled and age-specific prevalence and mortality associated with SAM. Documentation of key signs and symptoms (S/S) and performance of indicators of quality of care for selected aspects of the WHO management steps were assessed. Logistic regression models were used to evaluate associations between documented S/S and mortality among SAM patients aged 6–59 months. Loess curves were used to explore performance change over time for indicators of selected SAM management steps. Results: 5306/54140 (9.8%) children aged 1–59 months admitted with medical conditions in CIN hospitals between December 2013 and November 2016 had SAM. SAM prevalence identified by clinicians and case fatality varied widely across hospitals with median proportion (range) of 10.1% (4.6–18.2%) and 14.8% (6.0–28.6%) respectively. Seventeen variables were associated with increased mortality. Performance change over time of management steps varied across hospitals and across selected indicators but suggests some effect of regular audit and feedback. Conclusion: Identification of SAM patients, their mortality and adherence to in-patient management recommendations varied across hospitals. An important group of SAM patients are aged less than 6 months. Continued efforts are required to improve management of SAM in routine settings as part of efforts to reduce inpatient mortality. [ABSTRACT FROM AUTHOR]

Introduction: Appropriate demand for, and supply of, high quality essential neonatal care is key to improving newborn survival but evaluating such provision has received limited attention in low- and middle-income countries. Moreover, specific local data are needed to support healthcare planning for this vulnerable population. Methods: We conducted health facility assessments between July 2015-April 2016, with retrospective review of admission events between 1st July 2014 and 30th June 2015, and used estimates of population-based incidence of neonatal conditions in Nairobi to explore access and evaluate readiness of public, private not-for-profit (mission), and private-for-profit (private) sector facilities providing 24/7 inpatient neonatal care in Nairobi City County. Results: In total, 33 (4 public, 6 mission, and 23 private) facilities providing 24/7 inpatient neonatal care in Nairobi City County were identified, 31 were studied in detail. Four public sector facilities, including the only three facilities in which services were free, accounted for 71% (8,630/12,202) of all neonatal admissions. Large facilities (>900 annual admissions) with adequate infrastructure tended to have high bed occupancy (over 100% in two facilities), high mortality (15%), and high patient to nurse ratios (7–15 patients per nurse). Twenty-one smaller, predominantly private, facilities were judged insufficiently resourced to provide adequate care. In many of these, nurses provided newborn and maternity care simultaneously using resources shared across settings, newborn care experience was likely to be limited (<50 cases per year), there was often no resident clinician, and sick babies were often referred onwards. Results suggest 44% (9,764/21,966) of Nairobi’s small and sick newborns may not access any of the identified facilities and a further 9% (2,026/21,966) access facilities judged to be inadequately equipped. Conclusion: Over 50% of Nairobi’s sick newborns may not access a facility with adequate resources to provide essential care. A very high proportion of care accessed is provided by four public and one low cost mission facility; these face major challenges of high patient acuity (high mortality), high patient to nurse ratios, and often overcrowding. Reducing high neonatal mortality in this urban, predominantly poor, population will require effective long-term, multi-sectoral planning and investment. [ABSTRACT FROM AUTHOR]

Purpose: Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. Methods: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. Results: The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. Conclusions: The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care. [ABSTRACT FROM AUTHOR]

Background: The GAVI Alliance supported10-valent pneumococcal conjugate vaccine (PCV10) introduction in Kenya. We estimated the cost-effectiveness of introducing either PCV10 or the13-valent vaccine (PCV13) from a societal perspective and explored the incremental impact of including indirect vaccine effects. Methods: The costs and effects of pneumococcal vaccination among infants born in Kenya in 2010 were assessed using a decision analytic model comparing PCV10 or PCV13, in turn, with no vaccination. Direct vaccine effects were estimated as a reduction in the incidence of pneumococcal meningitis, sepsis, bacteraemic pneumonia and non-bacteraemic pneumonia. Pneumococcal disease incidence was extrapolated from a population-based hospital surveillance system in Kilifi and adjustments were made for variable access to care across Kenya. We used vaccine efficacy estimates from a trial in The Gambia and accounted for serotype distribution in Kilifi. We estimated indirect vaccine protection and serotype replacement by extrapolating from the USA. Multivariable sensitivity analysis was conducted using Monte Carlo simulation. We assumed a vaccine price of US$ 3.50 per dose. Findings: The annual cost of delivering PCV10 was approximately US$14 million. We projected a 42.7% reduction in pneumococcal disease episodes leading to a US$1.97 million reduction in treatment costs and a 6.1% reduction in childhood mortality annually. In the base case analysis, costs per discounted DALY and per death averted by PCV10, amounted to US$ 59 (95% CI 26–103) and US$ 1,958 (95% CI 866–3,425), respectively. PCV13 introduction improved the cost-effectiveness ratios by approximately 20% and inclusion of indirect effects improved cost-effectiveness ratios by 43–56%. The break-even prices for introduction of PCV10 and PCV13 are US$ 0.41 and 0.51, respectively. Conclusions: Introducing either PCV10 or PCV13 in Kenya is highly cost-effective from a societal perspective. Indirect effects, if they occur, would significantly improve the cost-effectiveness. [ABSTRACT FROM AUTHOR]

Background: Best formats for summarising and presenting evidence for use in clinical guideline development remain less well defined. We aimed to assess the effectiveness of different evidence summary formats to address this gap. Methods: Healthcare professionals attending a one-week Kenyan, national guideline development workshop were randomly allocated to receive evidence packaged in three different formats: systematic reviews (SRs) alone, systematic reviews with summary-of-findings tables, and 'graded-entry' formats (a 'front-end' summary and a contextually framed narrative report plus the SR). The influence of format on the proportion of correct responses to key clinical questions, the primary outcome, was assessed using a written test. The secondary outcome was a composite endpoint, measured on a 5-point scale, of the clarity of presentation and ease of locating the quality of evidence for critical neonatal outcomes. Interviews conducted within two months following completion of trial data collection explored panel members' views on the evidence summary formats and experiences with appraisal and use of research information. Results: 65 (93%) of 70 participants completed questions on the prespecified outcome measures. There were no differences between groups in the odds of correct responses to key clinical questions. 'Graded-entry' formats were associated with a higher mean composite score for clarity and accessibility of information about the quality of evidence for critical neonatal outcomes compared to systematic reviews alone (adjusted mean difference 0.52, 95% CI 0.06 to 0.99). There was no difference in the mean composite score between SR with SoF tables and SR alone. Findings from interviews with 16 panelists indicated that short narrative evidence reports were preferred for the improved clarity of information presentation and ease of use. Conclusions: Our findings suggest that 'graded-entry' evidence summary formats may improve clarity and accessibility of research evidence in clinical guideline development. [ABSTRACT FROM AUTHOR]

Background: The existing case fatality estimates of inpatient childhood pneumonia in developing countries are largely from periods preceding routine use of conjugate vaccines for infant immunization and such primary studies rarely explore hospital variations in mortality. We analysed case fatality rates of children admitted to nine Kenyan hospitals with pneumonia during the era of routine infant immunization with Hib conjugate vaccine to determine if significant variations exist between hospitals. Methods: Pneumonia admissions and outcomes in paediatric wards are described using data collected over two time periods: a one-year period (2007-2008) in nine hospitals, and data from a 9.25-year period (1999-March 2008) in one of the participating hospitals. Hospital case fatality rates for inpatient pneumonia during 2007 to 2008 were modeled using a fixed effect binomial regression model with a logit link. Using an interrupted time series design, data from one hospital were analysed for trends in pneumonia mortality during the period between 1997 and March 2008. Results: Overall, 195 (5.9%) children admitted to all 9 hospitals with pneumonia from March 2007 to March 2008 died in hospital. After adjusting for child's sex, comorbidity, and hospital effect, mortality was significantly associated with child's age (p<0.001) and pneumonia severity (p<0.001). There was evidence of significant variations in mortality between hospitals (LR χ² = 52.19; p<0.001). Pneumonia mortality remained stable in the periods before (trend -0.03, 95% CI -0.1 to 0.02) and after Hib introduction (trend 0.04, 95% CI -0.04 to 0.11). Conclusions: There are important variations in hospital-pneumonia case fatality in Kenya and these variations are not attributed to temporal changes. Such variations in mortality are not addressed by existing epidemiological models and need to be considered in allocating resources to improve child health. [ABSTRACT FROM AUTHOR]

Background: Implementation of WHO case management guidelines for serious common childhood illnesses remains a challenge in hospitals in low-income countries. The impact of locally adapted clinical practice guidelines (CPGs) on the quality-of-care of patients in tertiary hospitals has rarely been evaluated. Methods and Findings: We conducted, in Kenyatta National Hospital, an uncontrolled before and after study with an attempt to explore intervention dose-effect relationships, as CPGs were disseminated and training was progressively implemented. The emergency triage, assessment and treatment plus admission care (ETAT+) training and locally adapted CPGs targeted common, serious childhood illnesses. We compared performance in the pre-intervention (2005) and postintervention periods (2009) using quality indicators for three diseases: pneumonia, dehydration and severe malnutrition. The indicators spanned four domains in the continuum of care namely assessment, classification, treatment, and follow-up care in the initial 48 hours of admission. In the pre-intervention period patients' care was largely inconsistent with the guidelines, with nine of the 15 key indicators having performance of below 10%. The intervention produced a marked improvement in guideline adherence with an absolute effect size of over 20% observed in seven of the 15 key indicators; three of which had an effect size of over 50%. However, for all the five indicators that required sustained team effort performance continued to be poor, at less than 10%, in the post-intervention period. Data from the five-year period (2005-09) suggest some dose dependency though the adoption rate of the best-practices varied across diseases and over time. Conclusion: Active dissemination of locally adapted clinical guidelines for common serious childhood illnesses can achieve a significant impact on documented clinical practices, particularly for tasks that rely on competence of individual clinicians. However, more attention must be given to broader implementation strategies that also target institutional and organisational aspects of service delivery to further enhance quality-of-care. [ABSTRACT FROM AUTHOR]

Background: Modelling is widely used to inform decisions about management of malaria and acute febrile illnesses. Most models depend on estimates of the probability that untreated patients with malaria or bacterial illnesses will progress to severe disease or death. However, data on these key parameters are lacking and assumptions are frequently made based on expert opinion. Widely diverse opinions can lead to conflicting outcomes in models they inform. Methods and Findings: A Delphi survey was conducted with malaria experts aiming to reach consensus on key parameters for public health and economic models, relating to the outcome of untreated febrile illnesses. Survey questions were stratified by malaria transmission intensity, patient age, and HIV prevalence. The impact of the variability in opinion on decision models is illustrated with a model previously used to assess the cost-effectiveness of malaria rapid diagnostic tests. Some consensus was reached around the probability that patients from higher transmission settings with untreated malaria would progress to severe disease (median 3%, inter-quartile range (IQR) 1-5%), and the probability that a non-malaria illness required antibiotics in areas of low HIV prevalence (median 20%). Children living in low transmission areas were considered to be at higher risk of progressing to severe malaria (median 30%, IQR 10-58%) than those from higher transmission areas (median 13%, IQR 7-30%). Estimates of the probability of dying from severe malaria were high in all settings (medians 60- 73%). However, opinions varied widely for most parameters, and did not converge on resurveying. Conclusions: This study highlights the uncertainty around potential consequences of untreated malaria and bacterial illnesses. The lack of consensus on most parameters, the wide range of estimates, and the impact of variability in estimates on model outputs, demonstrate the importance of sensitivity analysis for decision models employing expert opinion. Results of such models should be interpreted cautiously. The diversity of expert opinion should be recognised when policy options are debated. [ABSTRACT FROM AUTHOR]

The article offers information on the study which determined research priorities to contribute in the reduction of intrapartum-related neonatal death or birth asphyxia by 2015. It mentions the application of process developed by Clinical Health Nutrition Research Initiative (CHNRI) to contribute in the progress of Millennium Development Goals (MDG). It states the priorities including research on delivery or implementation, facility care at birth, and relationship of hypoxia and infection.

Background: Case management guidelines use a limited set of clinical features to guide assessment and treatment for common childhood diseases in poor countries. Using video records of clinical signs we assessed agreement among experts and assessed whether Kenyan health workers could identify signs defined by expert consensus. Methodology: 104 videos representing 11 clinical sign categories were presented to experts using a web questionnaire. Proportionate agreement and agreement beyond chance were calculated using kappa and the AC1 statistic. 31 videos were selected and presented to local health workers, 20 for which experts had demonstrated clear agreement and 11 for which experts could not demonstrate agreement. Principal Findings: Experts reached very high level of chance adjusted agreement for some videos while for a few videos no agreement beyond chance was found. Where experts agreed Kenyan hospital staff of all cadres recognised signs with high mean sensitivity and specificity (sensitivity: 0.897-0.975, specificity: 0.813-0.894); years of experience, gender and hospital had no influence on mean sensitivity or specificity. Local health workers did not agree on videos where experts had low or no agreement. Results of different agreement statistics for multiple observers, the AC1 and Fleiss' kappa, differ across the range of proportionate agreement. Conclusion: Videos provide a useful means to test agreement amongst geographically diverse groups of health workers. Kenyan health workers are in agreement with experts where clinical signs are clear-cut supporting the potential value of assessment and management guidelines. However, clinical signs are not always clear-cut. Video recordings offer one means to help standardise interpretation of clinical signs. [ABSTRACT FROM AUTHOR]

Background: Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya. Methods/Principal Findings: We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group, n = 55). The training was adapted locally from the approach of the UK Resuscitation Council. The primary outcome was the proportion of appropriate initial resuscitation steps with the frequency of inappropriate practices as a secondary outcome. Data were collected on 97 and 115 resuscitation episodes over 7 weeks after early training in the intervention and control groups respectively. Trained providers demonstrated a higher proportion of adequate initial resuscitation steps compared to the control group (trained 66% vs control 27%; risk ratio 2.45, [95% CI 1.75-3.42], p,0.001, adjusted for clustering). In addition, there was a statistically significant reduction in the frequency of inappropriate and potentially harmful practices per resuscitation in the trained group (trained 0.53 vs control 0.92; mean difference 0.40, [95% CI 0.13-0.66], p = 0.004). Conclusions/Significance: Implementation of a simple, one day newborn resuscitation training can be followed immediately by significant improvement in health workers' practices. However, evidence of the effects on long term performance or clinical outcomes can only be established by larger cluster randomised trials. [ABSTRACT FROM AUTHOR]

Mike English and colleagues argue that we do not have sufficient evidence and health system capacity to abandon presumptive antimalarial treatment in children with fever in sub-Saharan Africa, countering the argument of Blaise Genton and colleagues in a related paper. [ABSTRACT FROM AUTHOR]

Background: Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use.Methods and Findings: We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups.Conclusions: There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized. [ABSTRACT FROM AUTHOR]

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) aims to work through learning, action, leadership and accountability. We aimed to evaluate the effectiveness of QCN in these four areas at the global level and in four QCN countries: Bangladesh, Ethiopia, Malawi and Uganda. This mixed method evaluation comprised 2-4 iterative rounds of data collection between 2019-2022, involving stakeholder interviews, hospital observations, QCN members survey, and document review. Qualitative data was analysed using a coding framework developed from underlying theories on network effectiveness, behaviour change, and QCN proposed theory of change. Survey data capturing respondents' perception of QCN was analysed with descriptive statistics. The QCN global level, led by the WHO secretariat, was effective in bringing together network countries' governments and global actors via providing online and in-person platforms for communication and learning. In-country, various interventions were delivered in 'learning districts', however often separately by different partners in different locations, and pandemic-disrupted. Governance structures for quality of care were set-up, some preceding QCN, and were found to be stronger and better (though often externally) resourced at national than local levels. Awareness of operational plans and network activities differed between countries, was lower at local than national levels, but increased from 2019 to 2022. Engagement with, and value of, QCN was perceived to be higher in Uganda and Bangladesh than in Malawi or Ethiopia. Capacity building efforts were implemented in all countries-yet often dependent on implementing partners and donors. QCN stakeholders agreed 15 core monitoring indicators though data collection was challenging, especially for indicators requiring new or parallel systems. Accountability initiatives remained nascent in 2022. Global and national leadership elements of QCN have been most effective to date, with action, learning and accountability more challenging, partner or donor dependent, remaining to be scaled-up, and pandemic-disrupted., Competing Interests: The authors have declared that no competing interests exist, (Copyright: © 2024 Djellouli et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) is intended to facilitate learning, action, leadership and accountability for improving quality of care in member countries. This requires legitimacy-a network's right to exert power within national contexts. This is reflected, for example, in a government's buy-in and perceived ownership of the work of the network. During 2019-2022 we conducted iterative rounds of stakeholder interviews, observations of meetings, document review, and hospital observations in Bangladesh, Ethiopia, Malawi, Uganda and at the global level. We developed a framework drawing on three models: Tallberg and Zurn which conceptualizes legitimacy of international organisations dependent on their features, the legitimation process and beliefs of audiences; Nasiritousi and Faber, which looks at legitimacy in terms of problem, purpose, procedure, and performance of institutions; Sanderink and Nasiritousi, to characterize networks in terms of political, normative and cognitive interactions. We used thematic analysis to characterize, compare and contrast institutional interactions in a cross-case synthesis to determine salient features. Political and normative interactions were favourable within and between countries and at global level since collective decisions, collaborative efforts, and commitment to QCN goals were observed at all levels. Sharing resources and common principles were not common between network countries, indicating limits of the network. Cognitive interactions-those related to information sharing and transfer of ideas-were more challenging, with the bi-directional transfer, synthesis and harmonization of concepts and methods, being largely absent among and within countries. These may be required for increasing government ownership of QCN work, the embeddedness of the network, and its legitimacy. While we find evidence supporting the legitimacy of QCN from the perspective of country governments, further work and time are required for governments to own and embed the work of QCN in routine care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Akter et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Multi-professional teams care for sick newborns, but nurses are the primary caregivers, making nursing care documentation essential for delivering high-quality care, fostering teamwork, and improving patient outcomes. We report on an evaluation of vital signs documentation following implementation of the comprehensive newborn monitoring chart using interrupted time series analysis and a review of filled charts. We collected post-admission vital signs (Temperature (T), Pulse (P), Respiratory Rate (R) and Oxygen Saturation (S)) documentation frequencies of 43,719 newborns with a length of stay > 48 hours from 19 public hospitals in Kenya between September 2019 and October 2021. The primary outcome was an ordinal categorical variable (no monitoring, monitoring 1 to 3 times, 4 to 7 times and 8 or more times) based on the number of complete sets of TPRS. Descriptive analyses explored documentation of at least one T, P, R and S. The percentage of patients in the no-monitoring category decreased from 68.5% to 43.5% in the post-intervention period for TPRS monitoring. The intervention increased the odds of being in a higher TPRS monitoring category by 4.8 times (p<0.001) and increased the odds of higher monitoring frequency for each vital sign, with S recording the highest odds. Sicker babies were likely to have vital signs documented in a higher monitoring category and being in the NEST360 program increased the odds of frequent vital signs documentation. However, by the end of the intervention period, nearly half of the newborns did not have a single full set of TPRS documented and there was heterogenous hospital performance. A review of 84 charts showed variable documentation, with only one chart being completed as designed. Vital signs documentation fell below standards despite increased documentation odds. More sustained interventions are required to realise the benefits of the chart and hospital-specific performance data may help customise interventions., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Muinga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 303 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Mukinda et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The Quality of Care Network (QCN) is a global initiative that was established in 2017 under the leadership of WHO in 11 low-and- middle income countries to improve maternal, newborn, and child health. The vision was that the Quality of Care Network would be embedded within member countries and continued beyond the initial implementation period: that the Network would be sustained. This paper investigated the experience of actions taken to sustain QCN in four Network countries (Bangladesh, Ethiopia, Malawi, and Uganda) and reports on lessons learned. Multiple iterative rounds of data collection were conducted through qualitative interviews with global and national stakeholders, and non-participatory observation of health facilities and meetings. A total of 241 interviews, 42 facility and four meeting observations were carried out. We conducted a thematic analysis of all data using a framework approach that defined six critical actions that can be taken to promote sustainability. The analysis revealed that these critical actions were present with varying degrees in each of the four countries. Although vulnerabilities were observed, there was good evidence to support that actions were taken to institutionalize the innovation within the health system, to motivate micro-level actors, plan opportunities for reflection and adaptation from the outset, and to support strong government ownership. Two actions were largely absent and weakened confidence in future sustainability: managing financial uncertainties and fostering community ownership. Evidence from four countries suggested that the QCN model would not be sustained in its original format, largely because of financial vulnerability and insufficient time to embed the innovation at the sub-national level. But especially the efforts made to institutionalize the innovation in existing systems meant that some characteristics of QCN may be carried forward within broader government quality improvement initiatives., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lemma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Better policies, investments, and programs are needed to improve the integration and quality of maternal, newborn, and child health services. Previously, partnerships and collaborations that involved multiple countries with a unified aim have been observed to yield positive results. Since 2017, the WHO and partners have hosted the Quality of Care Network [QCN], a multi-country implementation network focused on improving maternal, neonatal, and child health care. In this paper, we examine the functionality of QCN in different contexts. We focus on implementation circumstances and contexts in four network countries: Bangladesh, Ethiopia, Malawi, and Uganda. In each country, the study was conducted over several consecutive rounds between 2019-2022, employing 227 key informant interviews with major stakeholders and members of the network countries, and 42 facility observations. The collected data were coded using Nvivo-12 software and categorized thematically. The study showed that individual, organizational and system-level circumstances all played an important role in shaping implementation success in network countries, but that these levels were inter-linked. Systems that enabled leadership, motivated and trained staff, and created a positive culture of data use were critical for policy-making including addressing financing issues-to the day-to-day practice improvement at the front line. Some characteristics of QCN actively supported this, for example, shared learning forums for continuous learning, a focus on data and tracking progress, and emphasising the importance of coordinated efforts towards a common goal. However, inadequate system financing and capacity also hampered network functioning, especially in the face of external shocks., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Tesfa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Critical illnesses cause several million deaths annually, with many of these occurring in low-resource settings like Kenya. Great efforts have been made worldwide to scale up critical care to reduce deaths from COVID-19. Lower income countries with fragile health systems may not have had sufficient resources to upscale their critical care. We aimed to review how efforts to strengthen emergency and critical care were operationalised during the pandemic in Kenya to point towards how future emergencies should be approached. This was an exploratory study that involved document reviews, and discussions with key stakeholders (donors, international agencies, professional associations, government actors), during the first year of the pandemic in Kenya. Our findings suggest that pre-pandemic health services for the critically ill in Kenya were sparse and unable to meet rising demand, with major limitations noted in human resources and infrastructure. The pandemic response saw galvanised action by the Government of Kenya and other agencies to mobilise resources (approximately USD 218 million). Earlier efforts were largely directed towards advanced critical care but since the human resource gap could not be reduced immediately, a lot of equipment remained unused. We also note that despite strong policies on what resources should be available, the reality on the ground was that there were often critical shortages. While emergency response mechanisms are not conducive to addressing long-term health system issues, the pandemic increased global recognition of the need to fund care for the critically ill. Limited resources may be best prioritised towards a public health approach with focus on provision of relatively basic, lower cost essential emergency and critical care (EECC) that can potentially save the most lives amongst critically ill patients., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: TB: Technical consultancies with UNICEF, the World Bank, USAID and the Wellcome Trust, all outside the submitted work. ME: Financial competing interests – Grants from Wellcome and NIHR UK for research on hospital care in Kenya. Non-financial interest – Advisory roles for: WHO, Academy of Medical Sciences (UK), UKRI The other authors have no competing interests to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Oliwa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the clinical audit process must use a structured tool that comprehensively covers the continuum of newborn care from immediately after birth to the period of newborn unit care. The objective of the study was to co-design a newborn clinical audit tool that considered the key principles of a Human Centred Design approach. A three-step Human Centred Design approach was used that began by (1) understanding the context, the users and the available audit tools through literature, focus group discussions and a consensus meeting that was used to develop a prototype audit tool and its implementation guide, (2) the prototype audit tool was taken through several cycles of reviewing with users on real cases in a high volume newborn unit and refining it based on their feedback, and (3) the final prototype tool and the implementation guide were then tested in two high volume newborn units to determine their usability. Several cycles of evaluation and redesigning of the prototype audit tool revealed that the users preferred a comprehensive tool that catered to human factors such as reduced free text for ease of filling, length of the tool, and aesthetics. Identified facilitators and barriers influencing the newborn clinical audit in Kenyan public hospitals informed the design of an implementation guide that builds on the strengths and overcomes the barriers. We adopted a Human Centred Design approach to developing a newborn clinical audit tool and an implementation guide that we believe are comprehensive and consider the characteristics of the context of use and the user requirements., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ogola et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Networks are an often-employed approach to improve problems of poor service delivery and quality of care in sub-optimally functioning health systems. There are many types of health system networks reported in the literature and despite differences, there are identifiable common characteristics, uses, purposes, and stakeholders. This scoping review systematically searched the literature on networks in health systems to map the different types of networks to develop an understanding of what they are, when and what they are used for, and the purposes they intend to achieve. Peer-reviewed literature was systematically searched from six databases (Medline (Ovid), EMBASE (Ovid), Global Health (Ovid), the Cochrane Library, Web of Science Core Collection, Global Index Medicus's Africa Index Medicus) and grey literature was purposively searched. Data from the selected literature on network definitions, characteristics, stakeholders, uses, and purposes were charted. Drawing on existing frameworks and refining with the selected literature, a five-component framework (form and structure, governance and leadership, mode of functioning, resources, and communication), broadly characterizing a network, is proposed. The framework and mapping of uses, purposes, and stakeholders is a first step towards further understanding what networks are, when and what they are used for, and the purposes they intend to achieve in health systems., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: KK is a consultant for the World Health Organization on networks of care for maternal and newborn health. ME established the Clinical Information Network in Kenya and receives funding for this research platform., (Copyright: © 2023 Kalaris et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The objectives of this study were to (1)explore the quality of clinical data generated from hospitals providing in-patient neonatal care participating in a clinical information network (CIN) and whether data improved over time, and if data are adequate, (2)characterise accuracy of prescribing for basic treatments provided to neonatal in-patients over time. This was a retrospective cohort study involving neonates ≤28 days admitted between January 2018 and December 2021 in 20 government hospitals with an interquartile range of annual neonatal inpatient admissions between 550 and 1640 in Kenya. These hospitals participated in routine audit and feedback processes on quality of documentation and care over the study period. The study's outcomes were the number of patients as a proportion of all eligible patients over time with (1)complete domain-specific documentation scores, and (2)accurate domain-specific treatment prescription scores at admission, reported as incidence rate ratios. 80,060 neonatal admissions were eligible for inclusion. Upon joining CIN, documentation scores in the monitoring, other physical examination and bedside testing, discharge information, and maternal history domains demonstrated a statistically significant month-to-month relative improvement in number of patients with complete documentation of 7.6%, 2.9%, 2.4%, and 2.0% respectively. There was also statistically significant month-to-month improvement in prescribing accuracy after joining the CIN of 2.8% and 1.4% for feeds and fluids but not for Antibiotic prescriptions. Findings suggest that much of the variation observed is due to hospital-level factors. It is possible to introduce tools that capture important clinical data at least 80% of the time in routine African hospital settings but analyses of such data will need to account for missingness using appropriate statistical techniques. These data allow exploration of trends in performance and could support better impact evaluation, exploration of links between health system inputs and outcomes and scrutiny of variation in quality and outcomes of hospital care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Tuti et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised paper-based charts. We report on a process of implementing a comprehensive newborn monitoring chart and the perceptions of health workers in a network of hospitals in Kenya. The chart was launched virtually in July 2020 followed by learning meetings with nurses and the research team. This is a qualitative study involving document review, individual in-depth interviews with nurses and paediatricians and a focus group discussion with data clerks. The chart was co-designed by the research team and hospital staff then implemented using a trainer of trainers' model where the nurses-in-charge were trained on how to use the chart and they in turn trained their staff. Training at the hospital was delivered by the nurse-in-charge and/or paediatrician through a combined training with all staff or one-on-one training. The chart was well received with health workers reporting reduced writing, consolidated information, and improved communication as benefits. Implementation was facilitated by individual and team factors, complementary projects, and the removal of old charts. However, challenges arose related to the staff and work environment, inadequate supply of charts, alternative places to document, and inadequate equipment. The participants suggested that future implementation should be accompanied by mentorship or close follow-up, peer experience sharing, training at the hospital and in pre-service institutions and wider stakeholder engagement. Findings show that there are opportunities to improve the implementation process by clarifying roles relating to the filing system, improving the chart supply process, staff induction and specifying a newborn patient file. The chart did not meet the need for supporting documentation of long stay patients presenting an opportunity to explore digital solutions that might provide more flexibility and features., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Muinga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Globally, 2.4 million newborns die in the first month of life, with neonatal mortality rates (NMR) per 1,000 livebirths being highest in sub-Saharan Africa. Improving access to inpatient newborn care is necessary for reduction of neonatal deaths in the region. We explore the relationship between distance to inpatient hospital newborn care and neonatal mortality in Kenya. Data on service availability from numerous sources were used to map hospitals that care for newborns with very low birth weight (VLBW). Estimates of livebirths needing VLBW services were mapped from population census data at 100 m spatial resolution using a random forest algorithm and adjustments using a systematic review of livebirths needing these services. A cost distance algorithm that adjusted for proximity to roads, road speeds, land use and protected areas was used to define geographic access to hospitals offering VLBW services. County-level access metrics were then regressed against estimates of NMR to assess the contribution of geographic access to VLBW services on newborn deaths while controlling for wealth, maternal education and health workforce. 228 VLBW hospitals were mapped, with 29,729 births predicted as requiring VLBW services in 2019. Approximately 80.3% of these births were within 2 hours of the nearest VLBW hospital. Geographic access to these hospitals, ranged from less than 30% in Wajir and Turkana to as high as 80% in six counties. Regression analysis showed that a one percent increase in population within 2 hours of a VLBW hospital was associated with a reduction of NMR by 0.24. Despite access in the country being above the 80% threshold, 17/47 counties do not achieve this benchmark. To reduce inequities in NMR in Kenya, policies to improve care must reduce geographic barriers to access and progressively improve facilities' capacity to provide quality care for VLBW newborns., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Ouma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The first case of severe acute respiratory coronavirus 2 (SARS-CoV-2) was identified in March 2020 in Kenya resulting in the implementation of public health measures (PHM) to prevent large-scale epidemics. We aimed to quantify the impact of COVID-19 confinement measures on access to inpatient services using data from 204 Kenyan hospitals. Data on monthly admissions and deliveries from the District Health Information Software version 2 (DHIS 2) were extracted for the period January 2018 to March 2021 stratified by hospital ownership (public or private) and adjusting for missing data using multiple imputation (MI). We used the COVID-19 event as a natural experiment to examine the impact of COVID-19 and associated PHM on use of health services by hospital ownership. We estimated the impact of COVID-19 using two approaches; Statistical process control (SPC) charts to visualize and detect changes and Interrupted time series (ITS) analysis using negative-binomial segmented regression models to quantify the changes after March 2020. Sensitivity analysis was undertaken to test robustness of estimates using Generalised Estimating Equations (GEE) and impact of national health workers strike on observed trends. SPC charts showed reductions in most inpatient services starting April 2020. ITS modelling showed significant drops in April 2020 in monthly volumes of live-births (11%), over-fives admissions for medical (29%) and surgical care (25%) with the greatest declines in the under-five's admissions (59%) in public hospitals. Similar declines were apparent in private hospitals. Health worker strikes had a significant impact on post-COVID-19 trends for total deliveries, live-births and caesarean section rate in private hospitals. COVID-19 has disrupted utilization of inpatient services in Kenyan hospitals. This might have increased avoidable morbidity and mortality due to non-COVID-19-related illnesses. The declines have been sustained. Recent data suggests a reversal in trends with services appearing to be going back to pre- COVID levels., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2021 Wambua et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Case management guidelines use a limited set of clinical features to guide assessment and treatment for common childhood diseases in poor countries. Using video records of clinical signs we assessed agreement among experts and assessed whether Kenyan health workers could identify signs defined by expert consensus., Methodology: 104 videos representing 11 clinical sign categories were presented to experts using a web questionnaire. Proportionate agreement and agreement beyond chance were calculated using kappa and the AC1 statistic. 31 videos were selected and presented to local health workers, 20 for which experts had demonstrated clear agreement and 11 for which experts could not demonstrate agreement., Principal Findings: Experts reached very high level of chance adjusted agreement for some videos while for a few videos no agreement beyond chance was found. Where experts agreed Kenyan hospital staff of all cadres recognised signs with high mean sensitivity and specificity (sensitivity: 0.897-0.975, specificity: 0.813-0.894); years of experience, gender and hospital had no influence on mean sensitivity or specificity. Local health workers did not agree on videos where experts had low or no agreement. Results of different agreement statistics for multiple observers, the AC1 and Fleiss' kappa, differ across the range of proportionate agreement., Conclusion: Videos provide a useful means to test agreement amongst geographically diverse groups of health workers. Kenyan health workers are in agreement with experts where clinical signs are clear-cut supporting the potential value of assessment and management guidelines. However, clinical signs are not always clear-cut. Video recordings offer one means to help standardise interpretation of clinical signs.