In developing countries, one child in 10 dies before its fifth birthday. District hospitals are essential for providing health care to children in these countries. Many district hospitals in sub-Saharan Africa remain under-resourced, with poorly trained staff, run-down equipment, and a lack of drugs and supplies. Tackling these problems requires local, national and international action.

The Kenya Medical Research Institute/Wellcome Trust Programme's Centre for Geographic Medicine Research, in Kilifi, Kenya, assessed the quality and performance of inpatient paediatric care in 14 district hospitals throughout the country. 

The information collected showed considerable differences between hospitals. Death caused by anaemia ranged from 3 to 46 percent while overall child mortality ranged between 4 and 15 percent. There were significant problems with the data. Data was either not standardised between hospitals, or missing.  Despite 15 percent of adults being HIV positive, the children were rarely reported as having HIV.  Clinicians reported some medical symptoms, such as pallor, but many others were not recorded.  The recording of a child's weight is crucial when calculating the drug dosage they will receive. However, in two thirds of cases the child’s weight was not recorded. The study also found that:

• Hospitals had basic supplies such as oxygen, antibiotics, anti-malarials and vitamin A but lacked others, such as magnesium sulphate, needed for eclampsia. 
• Very sick children were rarely seen by doctors and never seen by paediatricians when they were admitted to the hospital. 
• In cases of malaria, the child’s records did not indicate the severity of the illness which can be identified through symptoms such as a child's level of consciousness or problems with breathing.
• Only 3 percent of children with malaria were given the correct dosage of quinine.
• No lumbar punctures were carried out on the 46 children with possible meningitis.
• Most children with malnutrition did not receive appropriate treatment.
• Up to 40 percent of blood transfusions for anaemia may have been unnecessary, wasting a valuable resource and exposing the children to a risk of HIV and other infections.
• Antibiotics and intravenous fluids were poorly used in cases of diarrhoea.

Existing national and international guidelines for all these conditions were not followed.  Members of staff need better training and guidelines to ensure they make accurate diagnoses and follow the correct procedures for treatment.  The hospitals need more staff, drugs and equipment.  The report recommends the following:

• Clinical officers in particular should receive training before they begin working in hospitals.  They also need on-the-job training and supervision.
• A system of triage should be brought in, where the patients are treated in order of urgency.
• Guidelines must be introduced on the correct methods for treating different illnesses so that the officers follow standard procedures.
• Medical records must be improved so that accurate information is available.
• The hospitals’ work should be monitored so that improvements can be made when they are needed.

Tackling these problems might need local, national, or even international action.  At an international level, vital mineral supplements for malnourished children must be made available from a reliable source.  At a national level, the essential drugs list should be amended to include Vitamin K.  Action can be taken at local level by using hospital income to buy food supplements.

Source(s):
‘Assessment of inpatient paediatric care in first referral level hospitals in 13 districts in Kenya’, The Lancet 363(9425): 1948-1953, by M. English, F. Esamai and A. Wasunna, 2004 Full document.

Funded by: Kenya Medical Research Institute; Wellcome Trust, UK

id21 Research Highlight: 23 March 2005

Further Information:
Mike English
KEMRI-Wellcome Trust Collaborative Programme
PO Box 43640
00100 GPO
Nairobi
Kenya

Contact the contributor: menglish@wtnairobi.mimcom.net

Kenya Medical Research Institute/Wellcome Trust Collaborative Programme

Other related links:
'Decisions, decisions – adapting the IMCI approach for Kenyan paediatric hospitals'

'Matching policy with practice: effectively treating childhood fever in Kenya'

'Coverage story: how to deliver better child survival'

'Targeting the causes of perinatal mortality in a Kenyan hospital'

'Time after time - why some children keep coming back to hospital'

See id21's collection of links relevant to maternal and child health.

See id21's collection of links relevant to health systems and economics.