Health Services that Deliver: Improving Care for Sick Newborns (HSD-N)

2009年，肯尼亚有42，000名新生儿死亡，占5岁以下儿童死亡总数的40%。新生儿死亡率如此之高，是肯尼亚未能按照既定目标成功降低儿童死亡率的一个主要原因。认识到这一点，卫生部已开始注重改善新生儿（和产妇）健康，制定了针对社区和小诊所的战略。然而，生病或脆弱的新生儿往往需要转诊设施的住院护理，由掌握基本技术的熟练工人提供。通常在该水平提供的干预措施包括，例如，为那些无法吸吮的人提供液体或饲料，或用于呼吸支持的氧气。这种干预措施要求护理人员每天多次执行相同的耗时任务，持续许多天。熟练卫生工作者的短缺往往意味着这些服务无法充分提供，可能会延迟或阻止康复。我们正在计划研究，以确定：严重新生儿疾病的潜在负担;现有的基础设施和人力资源能力支持这一人群的访问;这些服务的利用率;以及现有护理服务的质量。我们将以内罗毕的500万人口为重点，其中许多人非常贫穷。这项工作的重点是普遍覆盖和新生儿护理达到商定的标准，将为估计现有服务与所需服务之间的差距（差距1）以及现有服务与所需服务之间的质量差距（差距2）提供基础。我们将与重要的利益攸关方合作，探讨低收入国家如何最好地应对卫生人力挑战，以缩小这些差距，并以负担得起和有效的方式改善向所有患病新生儿提供的基本护理。研究的这一最终目标是由工资成本占医疗保健总成本的主要比例这一事实驱动的。因此，如果在专业人员的监督下，其他团体可以有效地提供必要的干预措施，那么一种选择就是探索雇用专业护士的替代方案--这种方法被称为任务转移。如果不考虑国家法规、重要专业人员、管理人员或家长的意见，可能会导致该方法被拒绝或失败。当被照顾的人生病、新生儿以及传统上由专业护士甚至专科护士提供日常护理时，考虑到当地情况可能特别重要。因此，首先，我们将与主要群体一起确定应该向所有人提供何种形式的护理，了解提供护理的现有法规，并考虑主要群体对任务转移的关切。我们将仔细检查护士在一系列不同设施中必须做的所有事情，与专家一起探索哪些任务可能对其他人来说足够简单，并检查是否有时间完成所有基本护理任务。我们将估计内罗毕对新生儿护理的需求量以及现有护理与需求之间的差距。利用所有这些数据，我们将探讨可能需要多少新的工作人员来改善为所有有需要的新生儿提供的基本护理。我们亦会进行初步工作，研究聘用额外专业护士或把工作转由其他成本较低的员工负责，以应付这方面的需要所需的费用。成本较低的工作人员可能发挥的作用将通过研究哪些任务需要转移以及他们如何适应现有的提供护理模式来了解。所有这些工作都将与保健方面的主要决策者、保健专业人员和家长一起进行，以制定适合当地条件的选择办法。在此基础上，我们的目标是制定一个任务转移的方法，可以在肯尼亚的未来进行测试。

In 2009, there were 42,000 newborn deaths and they accounted for 40% of all deaths among children under 5 Kenya. This high neonatal mortality is a major reason why Kenya is not succeeding in its battle to reduce child deaths in line with stated targets. Recognising this, the Ministry of Health has started to focus on improving newborn (and maternal) health with strategies aimed at communities and small clinics. However, sick or vulnerable newborns will often require inpatient care in referral facilities from skilled workers with access to basic technologies. Interventions typically delivered at this level include, for example, fluids or feeds for those unable to suck or oxygen for respiratory support. Such interventions require carers to perform the same, time-consuming tasks multiple times per day for many days. Shortage of skilled health workers often means these services are inadequately delivered, potentially delaying or preventing recovery.We are planning research that will establish: the potential burden of severe neonatal illness; what existing infrastructure and human resource capacity is available supporting access for this population; utilisation of these services; and the quality of existing nursing care services. We will do this focusing on Nairobi's population of 5 million, many of whom are very poor. With a focus on universal coverage and neonatal care meeting agreed standards, this work will provide the basis for estimating the gap between available and needed services (Gap 1) and the quality gap between existing and desired services (Gap 2). In partnership with important stakeholders, we will explore how a low-income country might best tackle health workforce challenges to close these gaps and improve provision of essential nursing care to all sick newborn babies in an affordable and efficient way. This ultimate aim of research is driven by the fact that salary costs are a major proportion of total health care costs. One option will therefore be to explore alternatives to employing professional nurses if necessary interventions can be effectively provided by other groups under the supervision of professionals - an approach known as task-shifting.Although task-shifting sounds a simple solution, it may not always be. Failure to consider national regulations, the opinions of important professionals, managers or parents may lead to the approach being rejected or failing. Taking account of the local situation may be particularly important when those being cared for are sick, newborn babies and when day to day care has traditionally been given by professional, even specialist nurses. First, therefore, we will define with the major groups what forms of care should be available to all, learn what regulations exist on providing care, and consider the concerns of major groups with respect to task-shifting. We will examine carefully all the things that nurses have to do in a range of different facilities, explore with experts which tasks may be simple enough for others to do, and examine whether there is time to do all the essential care tasks. We will estimate how much need there is for neonatal nursing care in Nairobi and the gap between what is available and what is needed. Using all these data we will explore how many new staff might be needed to improve the delivery of essential care for all newborns in need. We will also undertake preliminary work to explore the costs of meeting this need using extra professional nurses or if tasks were shifted to other, lower cost staff. Possible roles for lower cost staff will be informed by work examining what tasks to shift and how they might fit within existing patterns of providing care. All this work will be conducted with the major decision makers in health, health professionals and parents to develop options sensitive to local conditions. Based on this body of work we aim to develop a task-shifting approach that can be tested in Kenya in the future.