Improving neonatal health in remote rural areas in China and Vietnam

在中国和越南，新生儿（生命最初4周）的健康仍然是一个重大问题，特别是在农村地区，他们的死亡率是较发达地区的3至4倍。大多数新生儿可以在设施和社区一级采用成本效益高的干预措施进行治疗，不需要高水平培训或昂贵的设备。在最贫困地区实现这些干预措施的高覆盖率，可使新生儿死亡至少减少70%。虽然中国和越南在国家和地方层面都有指导适当护理和治疗的NH实践指南，但一个主要问题是指南的执行不力。本发展研究将评估与当地卫生管理人员一起使用参与性问题解决干预措施以改善NH指南实施的可行性。如果可行，它将为全面研究的设计提供信息，以评估干预措施的有效性。在全面研究中，研究小组将通过解决问题和规划讲习班、指导和能力发展来支持当地卫生管理人员，以：(1)评估当前指南的有效性；(2)确定与服务提供（例如劳动力问题、运输、设备和供应）和服务需求（受远程访问和传统信仰的限制）有关的改进实施的障碍；(3)在目前的资源限制下，制定可行的策略，例如重组服务和人力资源，以及采用适当的社区参与模式，以刺激对改善服务的需求；4)制定适当的方法来监测影响和意外后果。为了评估干预措施在中国和越南偏远农村的可行性，发展研究必须解决4个问题：1。当前的卫生服务管理实践和不同系统层面的决策自由度对改善NH结果的影响是什么？发展或加强社区行动以支持改善新卫生保健成果的机会有哪些？监测国家卫生健康结果和衡量不同卫生系统级别干预措施的成本效益的潜力是什么？地方管理者使用参与式问题解决干预来实施现有实践指南的可行性如何，以改善覆盖社区、初级和转诊水平的新卫生保健结果？干预的最佳工具是什么？我们计划在北京举行为期两天的研讨会，以完善我们的实地工作计划和数据收集工具，并进行3次全国关键信息提供者访谈（kii）之前，对NH实践指南、监测偏远地区NH影响的挑战和NH干预的成本效益进行桌面审查。然后，我们将使用4种方法在中国贵州收集数据：(i) kii：社区一级代表、当地卫生服务管理人员、一线卫生工作者和省级决策者和高级卫生官员；焦点小组讨论：新妈妈和社区成员；（iii）社区行动协议和省/国家政策和计划的文件审查；（iv）观察卫生管理信息系统（HMIS）和会计系统。在分析这两个国家的数据集之前，一个较小的研究小组将在越南的Tay Nguyen重复这一数据收集方案。这将为设计提供全面研究的信息，并促进利益相关者的参与。我们将在监测偏远地区的卫生保健服务方面产生3项产出；中国和越南偏远地区监测NH的可行性国家政策空间和地方决策自由，以改善卫生服务。三个层面的利益相关者将受益：地方（卫生服务管理人员和工作人员）、国家（中国妇幼保健中心和越南新卫生技术工作组的政策制定者）和国际（例如联合国儿童基金会、世卫组织、PMNCH和实施科学小组，如世卫组织领导的实施研究平台）。

Newborn (first 4 weeks of life) health remains a significant problem in China and Vietnam, especially in rural areas where they are 3 to 4 times more likely to die than in more developed areas. Most newborns can be treated with cost-effective interventions at facility and community levels, which do not require high-level training or costly equipment. Achieving high coverage of these interventions in the poorest areas could reduce neonatal deaths by at least 70%. While NH practice guidelines exist in China and Vietnam at national and local levels to guide on appropriate care and treatment, a major problem is ineffective implementation of the guidelines.This development study will assess the feasibility of using a participatory problem-solving intervention with local health managers to improve NH guideline implementation. If feasible, it will inform the design of a full-scale study to evaluate the effectiveness of the intervention. In the full-scale study, the research team would support local health managers through problem-solving and planning workshops, mentoring and capacity development to (1) assess the effectiveness of current guidelines; (2) identify barriers to improved implementation relating to service delivery (e.g. workforce issues, transport, equipment and supplies) and service demand (limited by remote access and traditional beliefs); (3) develop feasible strategies within current resource constraints e.g. re-organising services and the workforce, and using suitable community engagement models to stimulate demand for improved services; and 4) develop appropriate methods to monitor impact and unintended consequences.To assess the intervention's feasibility in remote, rural China and Vietnam the development study must address 4 questions:1. What are the current health service management practices and the degree of freedom for decision-making at different systems levels for improving NH outcomes?2. What are the opportunities for developing or strengthening community actions to support improved NH outcomes?3. What is the potential for monitoring NH outcomes and measuring cost-effectiveness of interventions at different health systems levels?4. What is the feasibility for local managers to use a participatory problem-solving intervention to implement existing practice guidelines for improving NH outcomes covering community, primary and referral levels and what would be the best vehicle for the intervention?We plan to conduct desk-based reviews of NH practice guidelines, challenges of monitoring NH impact in remote areas and NH intervention cost-effectiveness, before holding a 2-day workshop in Beijing to refine our field work plan and data collection tools and conduct 3 national key informant interviews (KIIs). We will then collect data in Guizhou, China using 4 methods: (i) KIIs: community level representatives, local health service managers, frontline health workers and provincial level policy makers and senior health officials; (ii) focus group discussions: recent mothers and community members; (iii) document review of community action agreements and provincial/national policies and plans; (iv) observation of health management information systems (HMIS) and accounting systems. A smaller research team will repeat this data collection protocol in Tay Nguyen, Vietnam, before analysing the two country datasets.This will inform the design the full-scale study and facilitate stakeholder engagement. We will produce 3 outputs on monitoring NH services in remote areas; practicalities of monitoring NH in remote China and Vietnam; and national policy space and local decision making freedom to improve NH services. Three levels of stakeholders will benefit: local (health service managers and staff), national (policy makers in China's MCH centres and Vietnam's NH technical working group) and international (e.g. Unicef, WHO, PMNCH and implementation science groups like WHO-led Implementation Research Platform).