Most facility delivered care results from the work of multiple individuals in diverse roles. Relations between all these people determine the nature of this care, and how different team members organise themselves around a new activity will impact the success of any intervention (eg, issues explored in detail in normalisation process theory).27 In most facilities therefore, local interpersonal and interprofessional relations, and team and facility management and leadership are key to an intervention’s success. In our own work, this is apparent from examples exploring the adoption of bedside technologies, laboratory-based diagnostics and broader efforts to promote the use of multiple, evidence-based guidelines (see panel 1).16 19 26 Although such relationships are often acknowledged as critically important post hoc in reports on intervention effectiveness they seem surprisingly rarely addressed as a deliberate part of interventions.
In panel 1, we illustrate how these three core resource areas may interact and how the effectiveness on health outcomes of discrete interventions targeting severe acute malnutrition (SAM) would be limited. Having highlighted core resource dimensions we turn attention now to the efforts that may be required to initiate and embed change in facilities to promote intervention effectiveness.
Panel 1: illustration of how challenges within the three core resource dimensions and their interaction affect the success of programmatic interventions, the example of care for SAM
The WHO and UNICEF have promoted use of the 10 steps for care of children with SAM for over 30 years. Hospitals might be expected as a default to be able to meet the key physical and material resource requirements for managing a common, serious condition. These span accommodation that can keep affected children warm at night and that supports infection prevention together with essential material resources enabling temperature measurement, testing for hypoglycaemia and anaemia and specific milk, feed and micronutrient therapies. Indeed, UNICEF works in many countries, and for many years has supplied facilities with prepackaged milk formula and solid feed preparations. A logical and widely used intervention to complement these material resources is dissemination of guidelines ideally as part of pre-service and in-service training to build capability among health workers to diagnose and manage SAM to improve outcomes. This approach to intervention, further enhanced by monitoring and feedback of quality of SAM care processes in hospitals, has been used in Kenya in various forms for over 15 years. However, while scaling up of guidelines and training has occurred with improvements in some practices, outcomes have remained largely unchanged.52 53
Factors contributing to persistently poor outcomes of care for SAM span the three core resource areas. Thus, after 15 years even larger hospitals still face major challenges in providing a safe physical environment with persistent water, sanitation and infection control challenges compounded by undersupply of key materials, for example those enabling bedside blood glucose testing.54 55 There is some improvement in skills (capability) of those who initiate clinical management. For example, in appropriate prescribing of specific milks or feeds, but the system relies on this being done by the most junior front-line staff. These personnel begin with limited capability and rarely gain expertise because of rapid rotation through different departments, while they have very limited supervision as there are too few senior staff.56 57 At the same time, too few nursing staff struggle to monitor sick children and consistently deliver even the most essential therapies.25 Both reflect problems of inadequate workforce capacity that have changed little over many years. A consequence of low staffing numbers is limited interaction between medical and nursing personnel and unclear roles for nutritionists, where these are actually available. Poor collaboration and teamwork contribute to delays in executing and sustaining treatment plans, and failings in recognising and dealing with complications. At the same time, mothers of children with SAM are often poorly engaged as carers, reflecting poor communication with staff, and may even be stigmatised as bad parents.58
Improving outcomes of SAM requires that these multiple challenges that span all three core resource dimensions are tackled holistically. This needs sustained effort with potentially even more far-reaching strategies required to improve outcomes after hospital discharge.59