Elsevier

The Lancet

Volume 364, Issue 9445, 30 October–5 November 2004, Pages 1622-1629
The Lancet

Public Health
Delivery of paediatric care at the first-referral level in Kenya

https://doi.org/10.1016/S0140-6736(04)17318-2Get rights and content

Summary

Background

We aimed to investigate provision of paediatric care in government district hospitals in Kenya. We surveyed 14 first-referral level hospitals from seven of Kenya's eight provinces and obtained data for workload, outcome of admission, infrastructure, and resources and the views of hospital staff and caretakers of admitted children. Paediatric admission rates varied almost ten-fold. Basic anti-infective drugs, clinical supplies, and laboratory tests were available in at least 12 hospitals, although these might be charged for on discharge. In at least 11 hospitals, antistaphylococcal drugs, appropriate treatment for malnutrition, newborn feeds, and measurement of bilirubin were rarely or never available. Staff highlighted infrastructure and human and consumable resources as problems. However, a strong sense of commitment, support for the work of the hospital, and a desire for improvement were expressed. Caretakers' views were generally positive, although dissatisfaction with the physical environment in which care took place was common. The capacity of the district hospital in Kenya needs strengthening by comprehensive policies that address real needs if current or new interventions and services at this level of care are to enhance child survival.

Section snippets

Survey procedures

Between July and October, 2002, a period spanning the end of the main malaria season where malaria transmission is seasonal, three teams of three to four people working in parallel at separate hospitals conducted the survey. All survey staff were skilled Kenyan health workers trained for 3 weeks in survey procedures, including pilot exercises in one district and one provincial hospital. Surveys took 10 continuous days at every site, spanned a weekend, and included supervision visits by the

Study sites

Kenya is divided administratively into eight provinces and 70 districts. After excluding one province, Nairobi, the capital city and environs, which we deemed unrepresentative, we aimed to sample the main government inpatient facility serving the population from 13 districts—two each from six provinces and one from a more sparsely populated province—taking into account the national distribution of facilities and population density.8 Although inpatient services can be provided by the private or

Findings of the survey

Survey teams visited 14 hospitals in 13 districts: one district had two designated district hospitals. None refused to participate.

In nine hospitals, malaria was the most usual reason for admitting a child and was at least the third commonest reason in all 14 hospitals. Of the 14 hospitals surveyed, no problems with availability were reported for mains electricity (7/14), mains water (9/14), transport for referral (9/14), patient and caretaker washing facilities (4/14), and staff handwashing

Interpretation

Much has been written about the need for something to be done to reduce child mortality in low-income countries.2, 10 However, although many methods are already available,11 very little attention is devoted in published work to how services can actually be provided. As a first step, we have attempted, in Kenyan district hospitals, to identify the everyday constraints encountered in providing care to very sick children.

We studied a convenience sample of first-referral level facilities. These

Hospital performance

What our approach and that of Nolan and colleagues12 indicates is that assessment of hospital performance, although in its infancy in low-income countries, provides ample evidence that current deficiencies must be addressed. Equitable roll-out of new programmes or new interventions that need a functioning hospital sector, including the treatment of AIDS patients with antiretroviral drugs, will be impossible if system deficiencies are not tackled or will worsen care in lower-profile areas if

Hospital resources

In addition to few staff, the resources available to the main inpatient paediatric clinical service providers, clinical officers, and nurses are suboptimum. Equipment and consumables for supportive care are generally absent—notably, adequate means to deliver oxygen and nutritional support for severely malnourished children or low birthweight or premature infants. These findings accord with observations from several developing countries.12 By contrast, supplies of basic anti-infective drugs are

Staff opinions

Resource constraints and difficult conditions of service have predictable effects on staff, who often feel the system falls short of their expectations (panel, table 3). For example, an inadequate supply of blood for transfusion was typically reported, perhaps reflecting the speed with which children die of anaemia,15 often before a suitable donor from the family can be found. However, staff generally seemed happy with the state of cleanliness in most hospitals, the time available to them to do

Caretakers' opinions

Although caretakers were mostly very grateful because the child's illness had resolved, they were sometimes dissatisfied. Dissatisfaction was most usually expressed with the physical environment in which care takes place, with delays in receiving attention, and with official and unofficial charges (panel 2). Caretakers were usually content with the technical aspects of their child's care, although serious limitations were apparent on detailed review,7 illustrating that such views are likely to

Aims for the future

How then are services to be improved? Although a wide range of interventions is likely to be needed, our results suggest some that warrant consideration. At the local level, some health workers had a very positive sense of vocation and a desire to pursue improvements, and despite the difficulties, many sick children were being given essential, probably lifesaving, care. Maximising the potential of these motivated individuals, facilitating the development of their technical and leadership

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