The period between birth and the first week of life is the riskiest and yet in most cases, coverage of skilled care for newborns drops during this critical period. The World Health Organization reports that the failure to reduce deaths in the first four weeks of life is one of the most significant barriers in achieving MDG 4.
Acute respiratory infections are the leading cause of global child mortality and respiratory conditions associated with premature birth contribute to about 30 percent of neonatal death. In developed health systems, such conditions can be treated using Continuous Positive Airway Pressure, or bCPAP, a therapy that delivers pressurized flow to an infant to prevent air sac collapse and makes breathing easier.
However, the typical bCPAP setup used in such settings costs anywhere from $6,000, making it inaccessible to most health facilities in developing countries. As such, the standard of care in resource-constrained settings for babies in respiratory distress is usually low-flow oxygen therapy, which on its own is inadequate.
Inspired by the dire need for this kind of technology in Malawi, a country with the world’s highest rate of preterm birth, a team of students and professors from Rice University developed a low-cost prototype using a plastic shoebox and simple aquarium pumps. At a prototype cost of just $160, they showed that their version of the bCPAP device produced pressures and flows comparable to versions used in the developed world. Clinical trials at the Queen Elizabeth Central Hospital in Malawi also showed a 27 percent absolute improvement in survival in babies put on bCPAP compared to those on oxygen therapy.
With a Saving Lives at Birth transition grant, an $800 version of the device known as the Pumani bCPAP is currently being rolled out to all government hospitals in Malawi. With additional funding from GlaxoSmithKline PLC and Save the Children, the rollout has been extended to three other countries in the subregion: Zambia, Tanzania and South Africa.
Our experience in Malawi has shown that successfully implementing a new health technology within a health system goes beyond just providing access to the technology. It is misleading to assume that simply delivering a new medical device will result in effective, efficient and frequent use. While health providers are the driving force behind many facility-based interventions, new and unfamiliar technologies can be intimidating.
As such, our implementation team developed a comprehensive training curriculum, which uses a mix of teaching methods and materials, to ensure that all new users are prepared to use the device. Health workers benefit from both a theoretical background of how the technology works and hands-on sessions, which give them a chance to build competency in using the device.
Unfortunately, periodic staff rotations, which have been a part of Malawi’s health system for years, threaten to nullify the impact of such training. Staff rotation, in and of itself, is not necessarily a bad thing as it gives nurses and clinicians a feel for the different medical specialties. The issue arises when these rotations do not include adequate orientation, especially on the use of new interventions or protocols in a specific department.
In the case of bCPAP, users must be comfortable with initiating treatment and monitoring a baby on the machine. However, newly rotated, untrained staff often lack the confidence to treat eligible patients and this results in missed opportunities to improve patient outcomes.
On the surface it may seem that simply training these newly rotated staff will solve this problem. However, in resource-constrained settings challenged by lack of funding and availability of staff, this approach is not sustainable and serves as a Band-Aid on a much deeper problem. Training can be costly and takes the already limited number of health workers away from their posts for significant periods of time.
Our team has attempted to address this issue with periodic on-the-job mentorships to help transfer knowledge and skills, and improve attitudes towards use of the new technology. On-the-job mentorships, led by more experienced staff, allow health workers to learn within their natural work environment without disrupting their schedules. Mentors use various evaluation and feedback tools to assess mentees pre- and post-mentorship, and are able to identify areas of weakness that need to be reinforced.
To ensure that health workers are being constantly engaged, each hospital is encouraged to identify a CPAP champion, a focal person who serves as a liaison between the implementation team and the facility. These “champion” nurses and clinicians feel a sense of ownership over the intervention and have the power to foster positive attitudes among their colleagues. Champions who show promise advance to become mentors both within and outside their various facilities, sharing their expertise with other health workers.
One of such champion is Indira Chikomoni, who has been a CPAP focal person at one of Malawi’s central hospitals for the last two years. Indira’s commitment led her to become a mentor who has now mentored more than 50 health workers in six district hospitals. Biannual meetings bring CPAP champions together to share experiences and data showing how their facilities are performing. These meetings provide a forum for health providers and the implementation team to discuss successes, challenges and potential solutions.
A longer-term strategy to ensure skill retention and continuity of use among health workers is to work toward making technologies such as bCPAP the standard of care within the healthcare system. In Malawi, this includes integrating bCPAP into curricula for nursing and clinical officer schools in the near future, to ensure that all graduates demonstrate competence. The Kamuzu College of Nursing, the country’s largest educator of nurses and midwives, currently includes bCPAP use in its coursework. Other stakeholders such as the Paediatric and Child Health Association of Malawi, are investing in comprehensive and standard protocols for neonatal care, including bCPAP therapy, to be used nationally.
Simple but innovative medical technologies, such as the Pumani bCPAP, have the potential to address some of the developing world’s biggest public health problems. However, these interventions do not work in isolation, and their success often depends heavily on the strengths of a health system and the commitment and competency of its workforce.
As the world’s focus shifts to achieving the Sustainable Development Goals, investments into such innovative solutions should include on-going capacity building for users to ensure sustainability. Thinking about how to regularly engage users in ways that acknowledge the realities of existing human resources policies such as regular staff rotations is also critical in identifying gaps and challenges innovators to further improve on interventions.