Title: IMPRESS: Innovative Management PRactices to Enhance hoSpital quality and Save lives in Malawi
Funder: Department of Health and Social Care

Abstract: We will examine if improving hospital management practices leads to better health outcomes and quality of clinical care at scale in the 36 largest hospitals in Malawi, an ODA priority African country. We will study quality through the lens of newborn survival, a sensitive tracer of overall quality of care. The research focuses on quality of care and health workforce management, two priority areas for this call._x000D_ _x000D_ Progress in maternal and neonatal mortality in Malawi has stalled despite the fact that most women now give birth in facilities. Mortality rates for small and sick neonates admitted to hospitals are extremely high. The high burden of hospital-acquired neonatal infections (HAI), with increasing anti-microbial resistance (AMR) indicates that patient safety and AMR stewardship are major quality challenges. At the clinical level, there is strong evidence from controlled studies on the effectiveness of health technologies. In practice, however, clinical care in this setting depends critically on factors at the organisational level, as exemplified by common problems such as drug stock-outs, staff absenteeism, and power outages. Recent evidence indicates that management practices – in the areas of human resource management, performance monitoring, target setting and operations – may be a driver of quality care but there are few relevant studies in low- and middle-income settings, especially ones powered for mortality outcomes. _x000D_ _x000D_ The research will build on an existing platform “Newborn Essential Solutions & Technologies” (NEST360) that provides a bundle of novel devices through government channels and collects rich patient level data on mortality and processes of care. Our multi-disciplinary team from the College of Medicine, University of Malawi and LSHTM will address the following interlinked objectives:_x000D_ 1. Adapt and validate measures of hospital and district management practices. Formative qualitative research and psychometric performance assessment will generate validated tools to measure management practices. _x000D_ 2. Examine the association between management practices and quality of clinical care. Data on management practices linked to patient level measures of clinical quality will provide observational evidence on which practices matter for quality._x000D_ 3. Co-design a problem-focused hospital management intervention and scalable delivery model. Stakeholder workshops that draw in national and international expertise will result in a theory-driven intervention to enhance hospital management practices._x000D_ 4. Evaluate effectiveness of hospital management intervention on neonatal mortality and secondary outcomes (including HAIs). A cluster RCT will generate evidence on the effects of enhancing hospital management practices on patient outcomes and clinical quality. _x000D_ 5. Assess acceptability, fidelity, and mechanisms of effect through qualitative research and estimate cost-effectiveness. A process evaluation and cost-effectiveness analysis will inform scale-up in Malawi and generalisability of the trial findings to other countries._x000D_ _x000D_ This research will generate novel evidence on hospital management practices, with two-way skills transfer between the UK and Malawi, strengthening capacity of health systems researchers and hospital staff. Through equitable partnership with government and global policy networks, results will impact policy, to the benefit of neonates at high risk in Malawi, and beyond.

Lay abstract: Every year 2.5 million newborns die. Most of these deaths happen in hospital and could be prevented. Babies in their first 28 days of life represent some of the most vulnerable users of the health system, as they can die quickly. Malawi was one of the fastest progressing countries in Africa for newborn survival, but progress has stalled. Now that most births happen in health facilities, there is an urgent need to improve hospital care for newborns and their families._x000D_ _x000D_ There is strong evidence that health technologies (e.g. drugs, equipment) are a necessary ingredient for improving survival of small and sick babies. However, in practice, babies do not always get these clinical interventions even when resources are available. Commonplace problems, such as drug stock-outs, absent staff, and power outages, are due to organisational failings that are rooted in poor management. Improving management practices – so that hospitals effectively manage staff, drugs and medical supplies, have sound financial management and are data-driven in how they make decisions – offers the potential to turn the situation around._x000D_ _x000D_ Building on an existing platform, Newborn Essential Solutions & Technologies (NEST360), we will identify practical ways to enhance management practices in the 36 largest hospitals (43,000 babies admitted per year) in Malawi, to improve quality of care and reduce newborn deaths. We will address what are three fundamental gaps in knowledge. First, until recently, we did not have the tools to measure the extent to which hospitals adopt management practices. Building on recent advances, we will adapt and validate tools to Malawi to measure management practices. Second, no interventions to enhance hospital management practices have been rigorously evaluated in low-resource settings. Working in partnership with the Ministry of Health, experts and other key partners, we will design a management intervention and then evaluate it using the gold-standard of a randomised controlled trial and other complementary methods. This will inform scale up to the entire country and generate findings that can inform policy in other countries. Third, it is rarely possible to measure lives saved in such health systems research. By building on the existing NEST360 network of 36 hospitals with detailed patient level information on newborns admitted to hospital, we will examine which management practices matter most for quality of care. _x000D_ _x000D_ At the core of the research is an equitable partnership between College of Medicine, University of Malawi and London School of Hygiene & Tropical Medicine. A multi-disciplinary team of health system researchers, epidemiologists, health economists, social scientists, clinicians, implementation scientists and statisticians will partner with the Ministry of Health to generate high quality evidence that has direct relevance for policy and practice in Malawi, the African region, and beyond. At all stages of the research, from the design through to the communication of the findings, we will engage with the local community. Our goal is to enhance the management of hospitals, ultimately for the benefit of small and sick neonates admitted to hospital.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH