NIHR HPSR-CA: Innovative management practices to enhance hopital quality and save lives in Malawi 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. 
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 stockouts, 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. 
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 for 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.
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. The research aims to examine whether enhanced management practices can improve health outcomes and clinical quality for newborns in hospitals in Malawi. A multi-disciplinary team from College of Medicine, University of Malawi, and London School of Hygience & Tropical Medine will address the following interlinked objectives:
1. Adapt and validate measures of hospital and district management practices.
2. Examine the association between management practices and quality of clinical care, and its variation by facility characteristics.
3. Co-design a problem-focused hospital management intervention and scalable delivery model.
4. Evaluate effectiveness of the intervention on neonatal mortality and secondary outcomes (including hospital-acquired infections) through a cluster randomised trial.
5. Assess the intervention’s acceptability, fidelity, and mechanisms through qualitative research and estimate its cost-effectiveness.