The evolution of RCPCH Global programmes
www.rcpch.ac.uk/global
Contents Overview 3 Context 4 RCPCH Global 6 From training to mentoring
8
From doctors to nurses...and back
10
From paediatrics to child health
11
From individual to institutional
12
Measuring change 14 Sustaining change 15 Conclusion 16 References 17
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
Overview As the global rate of deaths among children
Health system strengthening is a long-term
under 5 has fallen, new patterns of maternal,
commitment. It cannot be achieved through one-
newborn and child mortality and morbidity
off training courses, or even through repeated
are emerging – in the perinatal period around
technical interventions. It is unlikely to happen
delivery, in escalating noncommunicable
through disease-specific vertical programmes
paediatric disease, and in common childhood
and can be undermined by fragmented and
conditions too severe to be managed in
unpredictable relationships between international
community and primary settings alone. Yet
and domestic financing.2 Rather, progressively
strengthening secondary and tertiary levels of
stronger and more capable health systems are
care in low- and lower-middle income countries
the result of sustained partnership over the long
has lagged behind as a feature of health system
term – sharing clinical knowledge, enhancing
development.
health worker motivation, testing organisational
1
The Royal College of Paediatrics and Child Health Global Team (‘RCPCH Global’) is committed to supporting improvement in health care
efficiencies, and building care delivery systems that reflexively monitor, assess and improve the quality of the services they provide.
capability in low-income countries, with a focus
This report gives an overview of how RCPCH
on strengthening secondary care-working with
Global works, and how its operational strategy has
district hospitals or their equivalents. We believe
evolved to-date.
that strengthening secondary care is an important but under-valued contribution to integrated health systems in resource-poor settings. i
i.
This constitutes a part of the wider RCPCH international strategy. Our programmatic work in low-income countries is directed at quality improvement in basic care systems and skills, but our country strategies aim at the same time to promote more advanced development of paediatrics through curriculum and formal education and qualification processes, as well as supporting the emergence of leadership and advocacy skills in partner paediatric associations.
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3
Context
Context Global child mortality fell dramatically during the Millennium Development Goals (MDG) period between 1990 and 2015. Much of the reduction – from 12.7m to 5.9m deaths a year – was achieved through investments in community and primary care, driving down major causes of under-five death like measles, pneumonia and diarrhoea.3,4 Yet 15,000 children still die every day before their fifth birthday, mainly from avoidable or treatable causes; almost all of them in the developing world. Further, deeper and faster reductions will be needed if countries – in particular those in the lowand lower-middle income bracket – are to achieve the ambitious child survival targets set out in the Sustainable Development Goals (SDG).5 Progress in child survival and more equitable paediatric health now depends on stronger integration of levels of care with secondary facility-based care providing back-up where community and primary services reach their limit, and tertiary referral centres absorbing cases with more highly specialised needs.6,7
Launched in 1998, the Integrated Management of Childhood Illness (IMCI) programme has been adopted by a majority of developing countries (figure 1). We are now starting to see how weaknesses in integration between primary and secondary levels of care – and weaknesses in infrastructure, equipment, medications and health workforce at secondary level – threaten to constrain or undermine the further, future impact of these important grassroots investments. As mortality reduction in community and primary settings matures, managing more critically ill mothers, newborns and children will require higher level, facility-based care.ii 8,9 The rising demand for institutional delivery in many developing countries, the proportional rise of newborn mortality, the stark rate of global stillbirth, and the stubborn intractability of maternal mortality and morbidity all point to the need for more accessible, and higher quality, hospital-based care.10, 11 Support for critically-ill infants and children in the secondary level of care is key to the efficacy of IMNCI, reducing
Figure 1: Countries with national IMNCI strategy, 2016 (source: WHO, 2017)
Yes No Unknown Not applicable
ii.
4
In Rwanda in 2013, for example, 4.36% of neonatal deaths were reported at primary healthcentre level; 75% were reported at ‘district hospitals’ (Rwanda-HMIS, 2013).
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
child mortality by as much as 44% in the areas such hospitals serve – as well as being an intrinsic goal of overall health system strengthening.12, 13 Strengthening systems of referral from community and primary, through secondary to tertiary and specialised care is key to the development of truly integrated healthcare. Improvement in the quality and efficiency of facility-based care will enable an appropriate balancing of resources in favour of new and emerging conditions associated with improved survival and broader drivers of chronic disease.
Yet almost half of the countries reported in the 2016 Global IMNCI Review had no facility-level paediatric care quality improvement programme.14 Patterns in the allocation of development assistance for health may have reinforced this problem. As overall aid spending and spending on ‘basic health’ programmes has risen, investments in structural development of national capabilities (‘policy and administrative capacity’, ‘basic infrastructure’ – specifically district hospitals – and ‘health personnel development’) have in relative terms stagnated. (figure 2).
“It is becoming increasingly apparent that hospital care for children is poor in many low-income settings. While there are proposed tools and international calls to change this situation, there have been only a handful of studies attempting to evaluate how to change such hospitals. More broadly, we still know little about how to change health worker behaviour and improve their performance in low-income settings.” 15
Figure 2: Development assistance for health (global, all donors, 1995-2016).iii 16000 14000
USD$m's
12000 10000 8000 6000 4000 2000 0 1995
1996
Total health
iii.
1997
1998
1999
2000 2001
2002 2003 2004 2005 2006 2007 2008 2009 2010
Health policy and administration
Basic healthcare
Basic health infrastructure
2011
2012
2013
2014
2015
2016
Health personnel development
OECD-Creditor Reporting System [accessed 2 November 2018], author’s calculations.
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5
RCPCH Global Support for global child health is written into the
today are rooted in early small-scale projects,
constitution of the Royal College of Paediatrics
roughly between 2011 and 2014, delivered under the
and Child Health. Since 2009, RCPCH Global has
rubric of Emergency Treatment Assessment and
been building a strategy to support paediatric
Treatment Plus in East Africa, complemented by
care quality in developing countries which
longer-term placement of ‘Global Links’ volunteers
reflects our comparative advantages and thus
working in selected hospitals (box 1).
best fit in an often crowded global health field.
Although we continue to use training protocols like
Our operational strategy is to support improvement
ETAT where appropriate, most of our programmatic
in the availability and quality of child health care in
work now is structured to support long-term,
secondary – district hospital-equivalent – facilities in
continuous quality improvement processes in the
low-income countries. The origins of our approach
facilities with which we are engaged.
Box 1: Emergency Triage Assessment & Treatment Plus (ETAT+) iv
skills, supporting symptomatic clinical decision-making including in situations with limited or no laboratory support.18, 19 In low-income contexts where the majority of child mortality and morbidity is associated
Deaths of children in hospital often occur within the first 24 hours of admission. Many of these deaths could be prevented if very sick children were identified and appropriate treatment started immediately upon their arrival at the health facility. This can be facilitated by rapid triage for all children presenting to the hospital in order to determine whether any emergency or priority signs are present and by providing appropriate emergency treatment.
with a small number of common conditions (malaria, malnutrition, diarrhoea/dehydration, meningitis, birth asphyxia, neonatal sepsis, prematurity & low birthweight) interventions along the lines of ETAT+ constitute a practical and realistic response.20 Although evaluation evidence is somewhat limited, where the impact of ETAT has been assessed, results have been positive, including: •
16
Reduction in inpatient mortality from 10-18% to 6-8% at Blantyre Hospital in Malawi.21
In the early 2000s, WHO endorsed emergency
•
severely malnourished children from 20%
paediatric care guidelines under the title
to 10% (part of the FEAST trial).22
ETAT (later ‘ETAT+’) aimed at improving the ability of clinicians in low-resource settings to identify children presenting with, inter alia, respiratory distress, shock, convulsions and severe dehydration.17 ETAT was designed to improve core paediatric
6
Reduction in anticipated mortality among
•
Reduction in early mortality from 47.6 to 37.9 deaths per 1000 admissions, and total mortality from 80.5 to 70.5 deaths per 1000 admissions in Lilongwe, Malawi.23
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
•
Reduction in case fatality from 12.4% to
WHO categorisation of very high value
5.9% at Ola During Children’s Hospital,
interventions.26
Sierra Leone. •
•
24
Given the high proportion of younger
Reduction in case fatality from 12% to 6%
patients presenting with more critical
in a Guatemalan public hospital.25
illness at hospital in low- and middle-
In Kenya, the cost of ETAT+ per disabilityadjusted life year (DALY) averted fell below USD$40 for a modelled 10% reduction from 7% baseline mortality – falling well within the
income countries, the case for investing in these facilities to continue reducing overall paediatric mortality is clear.27 Yet despite demand from countries, introduction of ETAT is still very low – acutely so in countries with the highest burden of child deaths.28
Adapt and amplify
paediatric quality of care. We now structure our
Whilst ETAT+ is a widely-respected and well-
with the central aim of building ‘credible local
understood course it is, in its original form, just a
institutions that can unlock the potential of expert,
course. ETAT+ can, without doubt, enhance critical
influential, local personnel’ working within the
life-saving knowledge and skills. But as – and
important but often neglected level of secondary
perhaps more – importantly, delivering ETAT+
care.
programme model according to these principles,
creates a defined entry point in any given facility for identifying, analysing and addressing the wider
These principles shift the focus of attention from
array of factors affecting institutional quality of
course-based interventions to sustainable quality
care for infants and children.
improvement processes. and are set out in the remainder of this report. 29, 30
In the process of delivering ETAT+ as short- course training, we have had the opportunity to engage with and understand the working conditions, needs and potential of clinicians in partner hospitals. How they may or may not be able to maximise benefit from training alone and the kinds of changes in the institutional systems of hospital and healthcare management which are needed to optimise clinicians’ ability to provide quality care day by day. The result of these early experiences is the development of a number of programmatic principles – of design, delivery and evaluation – which draw on and extend the underlying philosophy of ETAT+ to adapt and amplify its applications to perinatal, neonatal and wider
iv.
WHO published guidelines and training materials for paediatric Emergency Triage, Assessment and Treatment (ETAT) in 2005 (WHO, 2005a). Guidelines were adapted from Advanced Paediatric Life Support (APLS) protocols, modified for lowincome country conditions. Subsequent updates were carried out in 2013 (WHO, 2013a) and 2016 (WHO, 2016b).
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7
Principle 1. From training to mentoring There is now broad acknowledgment that short, stand-alone training courses, focusing on specific areas of clinical knowledge and practice, are inadequate as a means of fostering long-term, sustained improvement in the quality of clinical care.31, 32
increasingly on training delivered within the facilities in which trainees subsequently work, and expanding from simple course delivery to a combination of practice-based training reinforced by sustained mentoring, supervision and system change.40, 41
We know that centralised ex-situ training may be viewed as more efficient in terms of scale and speed of dissemination, but we know too that,
In Sierra Leone, we reconfigured the ETAT+ course as a 3-month modular programme of practicebased training, followed by 3 months of in-situ
delivered outside trainees’ real-world working environment, courses do not translate reliably into improved clinical practice.33 Basic knowledge and skills may improve immediately following training, but can deteriorate quickly and steeply.34
mentoring – based on the premise that lasting change in the context of resource-stretched facilities in Sierra Leone requires continuous support to ‘front-line workers’ through a cycle of implementation, review and refreshment until the clinical practices prescribed become individual and institutional habit.42, 43
Strengthening clinicians’ knowledge and skills without changing the environment in which they work, or the conditions of motivation and reward that inform their attitudes and behaviours, results in limited improvements in practice. Increasingly, ministries of health are shifting from conventional centralised, mass training programmes, in favour of sustained facility-based in-situ mentorship initiatives.35-39 ETAT+’s emphasis on practice-based simulation modes of training and skills development provided a foundation on which RCPCH Global has built its programme intervention design, concentrating
8
In Myanmar, we aligned ETAT+ with the national IMNCI guidelines, to create the Myanmar ‘Emergency Paediatric Care Programme’ (EPCP), delivered as periodic courses, but followed up with 6-month mentoring by UK clinicians working with the Myanmar Paediatric Society and local counterparts. Due to the step-wedge design, we were able to compare changes in clinical quality of care between hospitals receiving the full package of training and mentoring, and those in receipt only of training (figure 3).
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
Figure 3: Management of paediatric pneumonia, Myanmar Emergency Paediatric Care Programme 3.5 3
Likert Scale Score (1-5)
2.5 2 1.5 1 0.5 0
Baseline
6 months Average
Mentors and courses
12-24 months Courses
The reality of healthcare development is that
and change in the way healthcare facilities are
robust, national systems can take decades, not
structured and managed.
months or years, to develop and mature. In this sense, the training and mentorship delivered through our programmes is best understood not as an end in itself, but as a contributory input aiming to stimulate a much longer-term process of change – change in the thinking of clinicians about how care can be planned and delivered,
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The key to sustainability therefore is in finding, engaging with and supporting local clinical and administrative leaders willing to commit resources – principally, people and time – to embed in each hospital a continuous self-propagating cycle of teaching, learning, practice, audit and review.
9
Principle 2. From doctors to nurses...and back There is a striking discontinuity at the heart
capacity can be liberated through low-cost,
of health systems, not just in resource-poor
often cost-neutral changes to health policy and
countries, but across the world – that care is
institutional behaviour.
determined by doctors within the biomedical model but delivered much more concretely by nurses working within definitively human institutions and systems. Nurses constitute the majority of the facility-based health workforce in most low- and middle-income countries, yet they are, characteristically, under-appreciated,
In Sierra Leone, national ‘nurse-mentors’ have become the principal agents delivering our programme of training and mentoring to hospitals. Performance data show how quality of paediatric care has been sustained, comparing two 6-month intensive interventions, one (2017) with UK
under-valued and under-used.
clinicians embedded in each facility, the other
While there has been much discussion in
clinicians providing outreach support to locally-
recent years of ‘task-shifting’ and, perhaps more
managed ETAT Implementing Groups (EIG)
appropriately, ‘task sharing’ among clinical cadres,
(figure 4).
44
(2018) with Sierra Leone nurse-mentors and UK
we believe significant value among nurses – in motivation, capability and leadership – remains latent and unexploited. This is at best inefficient. The good news, though, is that it also suggests that there is a substantial amount of highquality clinical care capacity already in existence in hospitals and health facilities – and that this
Development and professionalisation of nursing and midwifery cadres was central to progress in maternal and child health improvement in Western Europe over the last century. We believe this hard-learnt lesson has much to offer health system strengthening in countries struggling to optimise limited human resources for health.
Figure 4: Quality of antimalarial prescription at programme hospitals, 2017 and 2018
100 95 90 85
%
80 75 70 65 60 55 50 Month 1
Month 2
Month 3 ETAT+ 2017
10
Month 4
Month 5
Month 6
ETAT+ 2018
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
Principle 3. From paediatrics to child health Our experience shows how simple training
Initial programmes designed to improve critical
protocols, targeting one aspect of hospital care
care for under-5s in Rwanda and Myanmar created
performance, can be used as an entry point for
the basis for expanding the model to enhance
wider improvement, as logical linkages between
neonatal survival, resulting in the development of
dimensions in the continuum of maternal,
complementary newborn care programmes, using
antenatal, neonatal and paediatric healthcare
the same methodology of in-situ, practice-based
make the breaching of departmental and
mentoring and systemic quality improvement.
specialty silos not only possible but inevitable.
In Rwanda, the objectives of improving neonatal
Improving survival in the first 24 hours at facilities
survival necessitated a complementary focus on
creates a new imperative – and opportunity – to
conditions in maternity and delivery and to the
strengthen post-admission care for critically-ill
development of a more comprehensive perinatal
children.45 In Sierra Leone, success with triage and
programme, incorporating neonatal, obstetric and
stabilisation led inevitably to a recognition of the
midwifery components, and spanning between
need to enhance post-admission care on the ward
primary and secondary facilities.
– in particular building the capability of nurses to monitor children, and identify and respond to deterioration. We believe that a combination of emergency and ward-based critical care will, over the longer term, be consolidated to form the basis of training for a new professional cadre of Sierra Leonean paediatric nurses.
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We have found that the basic tenets of quality improvement can be applied progressively outwards from a conventional approach to paediatrics. As a result, our model of programme development aims to expand multidisciplinary approaches and consolidate cross-specialty collaboration.
11
Principle 4. From individual to institutional Much effort has been expended over recent
attitudes and communication, access to drugs
decades in trying to improve the healthcare
and functioning equipment, and supportive
and clinical skills of individual practitioners –
supervision and leadership (figure 5).47-50 Whilst
with less attention to changing the institutional
training is an important component within this
contexts in which they work.
environment, it is not everything. Our programmes have evolved from interventions designed
Our experience is that changing the context – improving the physical condition of health facilities but also the institutional interaction between
primarily to deliver training to clinicians, to interventions designed to institutionalise the cycle of planning, implementation and assessment (or
policy-makers, administrative leaders, senior clinicians, junior doctors, nurses, midwives, clerks, patients and parents – is key to enhancing the
audit) which is foundational to genuine, lasting quality improvement.
impact of knowledge and skills and hence quality
At the heart of our programmes today is the
of care.
‘Hospital Improvement Plan’ (HIP) – a simple tool
46
bringing together the range of hospital actors,
RCPCH Global approaches the healthcare facility
providing them with a shared framework through
not as a collection of individual care interactions,
which to agree objectives, analyse barriers, identify
but as an integral whole in which quality of
solutions and assess progress (figure 6).
care is the combined effect of individual clinical knowledge, collective personal and professional
Figure 5: RCPCH Global’s concept of integrated institutional care strengthening Advocacy
Policy support and finance
Standards and guidelines
Infrastructure, water, energy
Procurement and supply
Hospital leadership Primary care
Referral transfer
Data and audit
Infrastructure, and space
Equipment and consumables
Community health
Facility assessment
Triage and emergency
Performance analysis
Audit, data, monitoring Discharge
Ward-based care Training/ mentoring
Health workforce 12
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
Our aim is that, at the point of programme
for action. Across multiple hospitals, the HIP
closure, a locally-owned HIP is adopted and in
creates a common language through which
regular use in each partner hospital. It is the
clinicians, who often work in considerable isolation
institutional commitment, shared by all staff from
from one another, can compare problems and
medical director to data officer, to set goals, test
share answers. And because some major factors
improvement strategies, and assess progress –
impeding quality improvement lie outside the
and to sustain this cycle continuously into the
control of hospital staff – reliable electricity and
future independently of external support – that
clean water, supply of critical commodities and
constitutes the clearest marker of programme
essential medicines, planning and stabilisation of
success.
adequate workforce – HIPs provide a framework
Within the hospital, a HIP can create a common framework through which different stakeholders in the care process can develop a shared agenda
which can clarify, evidence and thus strengthen local advocacy for changes which require nationallevel attention. vi
Figure 6: Excerpt from a Rwanda Neonatal Care Programme HIP, RCPCH Global 2018 Neonatal Action area
Problem (inc. baseline data if available)
Resuscitation
Training
• Functional resus area
Use of BVM
HBB training: on-ward simulation
Limited knowledge of HBB algorithm and skills to carry out resuscitation
Regular HBB training day
• Link with maternity
Proposed action
Progress (inc. most recent data if available
By whom and when
Equipment Suction (penguins)/ stethoscope (in theatre)/ small masks in maternity/ clock or timer/ resuscitation protocols
Improve equipment procurement/ provision
Champion, via Pharnacy by Dec 2018
create effective neonatal resuscitation area
RCPCH team by Nov 2018
Infrastructure No resus space in NICU
Create resuscitation space. Support new department planning.
Routine care
Training
• Monitoring and observations
Fluids rate and prescriptions (not using drip rate moderator)
Training on prescriptions; on-ward reinforcement. Burette giving sets; fob watches for nurses
RCPCH team and local champion by Feb 2019
Inconsistent temp control
Hypothermia training to all staff; training on incubator; temp control supplies in emergency transfer kit from health centres
RCPCH team and local champion by Feb 2019
Trophic feeds/ starting feeds/ documenting feeds/ ensuring feeds are done at all by carer
Education modules on feeding the preterm baby
RCPCH team
Easy provision and regular use of feeding charts
RCPCH team and local champion by Feb 2019
No lancets for BM
Urgent procurement of critical kit
Champions and RCPCH team; liaise with pharmacy
low stock of drugs; phenytoin, flucoxacillin, aciclovir
Improve procurement/ weekend supply
Champions/ pharmacy
• Feeding • Thermoregulation
Equipment
vi.
For example, in Rwanda, the national Neonatal Technical Working Group is looking at possible ways to influence design and construction of new hospital facilities, to ensure appropriate layout enhancing joined-up maternal and neonatal care.
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13
Principle 5. Measuring change For understandable reasons, governments and
performance assessment and review, as a critical
donors take a strong interest in mortality as the
component of life-saving care, and a key feature of
measure of child health and paediatric care.
institutional strengthening.
As a result, mortality tends to loom large as a
We aim to produce programme performance data
way of assessing a hospital’s performance. Yet
robust enough to publish, in particular where our
mortality is a rather blunt index. Understanding
programmes shed light on the complex interaction
how the range and interaction of contributory
of clinicians, patients and care delivery systems. And
factors within the hospital contribute to mortality– or survival – is vital if genuine, systemic
we know that credible statistics are key to building
improvements are to be made.
confidence with partner ministries and donor
Often, hospital statistics on mortality, especially
data produced by our interventions is the ‘short
where they are going in the wrong direction, can
feedback loop’ (the PDSA cycle at the heart of the
generate unhelpfully punitive responses. As a result,
WHO Quality of Care model, figure 7) – regularly
data tend to be viewed negatively. Clinicians can
showing colleagues in each hospital quantifiable
sometimes view data-gathering as a distraction
evidence of improvement, enabling them to invest
from provision of life-saving care. Hospital
in effective initiatives and correct ineffective ones
data officers tend to work in isolation feeding
and building confidence in the possibility of positive
performance data upwards to central ministry, but
change.
51
agencies. But by far the most important use of the
with limited direct feedback to the care providers within their facility. Without data, regularly supplied through local feedback, hospitals can end up
We aim to align with and support Hospital Management Information Systems (HMIS). But we
working more or less blind.
know that HMIS are often far from perfect. So we
RCPCH Global programmes are increasingly
through our programme designs, with a view to
grounded in robust data-gathering and evidence
merging key metrics and measurement approaches
of effect. We see the habit of data-gathering, of
with hospital data systems over time.
work to improve data quality, management and use
Figure 7: WHO
Quality of Care Framework
Quality of Care
Research WHO Guidelines
1. Establish leadership group 2. Situation analysis/ assessment 3. Adapt standards of care
Effective Implementation Strategies
4. Identify QI interventions
Plan 7. refinement of strategies
Learning System
Act
Do
5. Implementation of QI interventions
Capacity strengthening
Standards of Care
Study Measurement indicators and methods
6. Continuous measurement of quality & outcomes
Global Netrwork & Learning Platform
14
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
Principle 6. Sustaining change The key to genuine health system sustainability
care quality and outcomes, subjecting all activities
is not whether a hospital on its own can
to objective, evidence-led evaluation, to identify
maintain improvements achieved through our
what works best for children in their context.
partnership, but whether effective strategies for improvement identified in the course of that partnership are, ultimately, capable of being extended across the hospital network, financed
Sustainability does not hang on whether shortterm reductions in mortality achieved during an intervention are maintained – rather it depends on
and managed from domestic resources.
hospitals embracing mortality as a valued index
The key to sustainability of our programmatic work,
overall progress, through regular team review
then, is the extent to which we can support local
meetings in which all cadres are empowered to
colleagues – from medical superintendants and
speak and in which all facets of care quality are
hospital directors to house officers and nurses –
addressed.
to see the value of those strategies in their own working lives, and as a result to weave them into the fabric of standard working practice; and the extent to which we can persuade central policymakers to incorporate support for those strategies
of performance, and a starting point for gauging
Sustainability of the changes promoted by our interventions depends, in the end, on those changes being relatively low-cost or cost-neutral to our local counterparts. Changes to practice which
in their national planning processes.
require ongoing expense, add significant new
Sustainability does not depend on retention of our
engineering of institutional systems are unlikely to
teaching sessions – rather it depends on hospitals
last much beyond the end of an intervention.
agreeing to make regular teaching and refresher training part of their daily routine. Sustainability does not depend on local hospitals adopting international ‘best practice’ – rather it depends on administrators and clinicians, working together to create collective space and time to regularly review
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workload to busy schedules, or require major re-
Changes which are parsimonious, fitted to existing practices and systems, with no or limited additional resource requirements of money or time – and which can be shown to improve outcomes – are the ones for which the incentive to continue may outweigh the obstacles
15
Conclusion The key lesson from our experience over recent
•
We believe that in order to understand health
years is that strengthening a health system, or in
outcomes for children in facility-based care,
our case the secondary tier of the health system,
we need to understand better the processes of
takes time; and that short-term intervention (of
care-giving, and the attitudes and motivations
a few months, or a few years) is probably not, on
of care-providers. This requires development of
its own, going to be enough. This does not mean
new metrics, multidisciplinary methods of data-
that RCPCH Global aims to extend its presence in
gathering and analysis. There is a clear global
partner countries indefinitely. But it does mean
research agenda here.
that we approach with caution interventions shaped by cyclical funding and timebound,
•
But the primary role of data coming out of our
projectized implementation.
partnership programmes is in supporting regular,
•
We believe that training for knowledge and skills
where performance is improving and where
is an important piece of the quality improvement
problems remain. Institutionalising this feedback
puzzle, but it does not on its own adequately
loop, managed by data officers, monitored by
support clinicians struggling in extremely
facility administrators, and used by clinicians
challenging operational environments. Mentoring,
working as a team, is the critical change on which
using a quality improvement planning framework
much of the larger quality improvement premise
is, in our experience, a better way of instigating
is based.
timely feedback within each hospital, showing
a process towards lasting institutional change within the hospital as a whole. •
•
•
Whilst we plan our programmes with an eye to what happens after they are finished, we
Changing whole hospital systems is a daunting
approach partnership as a more continuous
prospect – in particular where resources are
concept. To be sure, we expect RCPCH Global’s
severely stretched. Starting with a more focused
role to change over time in our partner countries.
intervention, for example, concentrating on speed
Over the long term, we aim to shift from direct
of triage or basic improvements in the neonatal
support through field-based clinical volunteers
unit, can be helpful in demonstrating what is
to quality assurance, as local clinicians take over
possible to local administrators, doctors and
and maintain improvement strategies; and we
nurses, thus building a platform on which wider
aim to shift ‘upstream’, to support ministries and
improvement methods and initiatives can be
health education institutions develop pedagogical
progressively taken on.
and training methodologies for doctors, nurses, midwives and other cadres at source.
We strongly support a re-balancing of attention and investment across clinical cadres, with a
•
But for as long as there is value in a growing
particular focus on recognising and enhancing
international network of organisations dedicated
the role of nurses. We believe this can and should
to paediatric care and child health, acutely
be done as a collaborative enterprise with the
through humanitarian support to the world’s
medical community. In resource-poor settings,
poorest countries, RCPCH will continue to invest
investing in better-trained, better remunerated
in a clearly- defined, partnership-based global
nurses and midwives, supported by their medical
role.
colleagues and able to pursue stable specialised careers, is probably one of the most powerful measures available for global child health. 16
RCPCH Global 2014-2022: The evolution of RCPCH Global programmes
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Acknowledgements: We would like to thank the doctors, nurses, midwives, health assistants, data officers, hospital directors, medical superintendants, Ministry officials and government leaders who make the work described in this document possible. We would like to thank all the RCPCH members who work with us, on an entirely voluntary basis, in a wide range of capacities from senior clinical advisors to long-term mentors on the ground, often in remote and challenging environments. We would like to thank the other Medical Royal Colleges, the nurses, midwives, obstetricians and many others who work with us in our multidisciplinary programmes. We would like to thank the many international and local charities and NGOs with whom we work side by side. We would like to thank WHO and Unicef for their invaluable technical and financial assistance and collaboration. We would also like to thank the UK Government’s Department for International Development and the Jersey Overseas Aid Commission for their generous support.
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If you are interested in taking part in our programmes, please email: global@rcpch.ac.uk
ŠRCPCH 2019 The Royal College of Paediatrics and Child Health (RCPCH) is a registered charity in England and Wales (1057744) and in Scotland (SC038299).