RCPCH Global 2014-2022 - The evolution of RCPCH Global programmes

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).