56 SECTION I Pediatric Critical Care The Discipline Programs Organization Program Details Fellowships The African Paediatric Fellowship Programme University of Cape Town, South Africa African doctors[.]
Trang 156 SECTION I Pediatric Critical Care: The Discipline
Fellowships
The African Paediatric Fellowship
Programme University of Cape Town, South Africa African doctors spend 6 months to 2 years training in a pediatric subspecialty, including pediatric critical care Graduates then return to their home
institu-tion to build a practice, training, research, and advocacy
Pediatric Emergency and Critical
Care–Kenya University of Nairobi and AIC Kijabe Hospital, Kenya in collaboration
University of Washington, Seattle, Washington
Two-year program in pediatric emergency and critical care for African pediatri-cians Curriculum based on East African disease spectrum and resources
Short Courses
Emergency, triage, assessment
and treatment (ETAT) World Health Organization Teaches health workers of all levels to appropriately triage sick children on arrival to a health facility and to provide emergency treatment for
life-threatening conditions
Pediatric basic assessment and
support intensive care (BASIC) Created by leaders in pediatric critical care education Teaches nonintensivists the essential principles of recognizing and initiating care for the critically ill child in the absence of an intensivist; low cost Pediatric fundamentals of critical
care study (PFCCS) Society of Critical Care Medicine Teaches nonintensivists the essential principles of recognizing and initiating care for the critically ill child in the absence of an intensivist Tiered course
pricing based on a country’s gross domestic income
Pediatric advanced life support
(PALS) American Heart Association Teaches pediatric healthcare provider in developing the knowledge and skills necessary to efficiently and effectively manage critically ill infants and
chil-dren; targeted toward pediatricians, emergency physicians, family physi-cians, physician assistants, nurses, nurse practitioners, and paramedics Pediatric, emergency,
assessment, recognition
and stabilization (PEARS)
American Heart Association Teaches assessment, early recognition, prompt communication, and initial
intervention in pediatric critical illness by using high-performance team dynamics; targeted toward physicians and nurses not specializing in pediatrics, nurse practitioners, and physician assistants
Trauma team training (TTT) Canadian Network for International
surgery grants access to course materials
Low-cost course designed to teach a multidisciplinary team approach to trauma evaluation and resuscitation with the limited resources found at African rural hospitals and health centers
TABLE
8.1 Examples of Pediatric Critical Care Education Available in Lower-Middle-Income Countries
LMICs, such as Trinidad, India, Ecuador, and Tanzania.94–97 In
fields such as pediatric surgery and obstetrics, short-term,
special-ized training courses have been correlated to increased knowledge
retention.98 , 99 Training of Kenyan doctors taking the
Fundamen-tal Critical Care Study course has been shown to increase their
knowledge of and confidence in new critical care skills.100
A Cochrane review assessed the effects of in-service emergency
care training on health professionals’ treatment of severely ill
newborns and children in LICs.101 It included only two neonatal
resuscitation studies, both of which suggested a beneficial effect
on health provider outcomes (resuscitation practices, assessment
of breathing, resuscitation preparedness) in the short term
How-ever, the effects on neonatal mortality outcomes were
inconclu-sive, and improvement in health provider practices after training
was not generalizable Therefore, decisions to scale up life
sup-port courses in LICs “must be based on consideration of costs
and logistics associated with their implementation, including the
need for adequate numbers of skilled instructors, appropriate
locally adapted training materials and the availability of basic
resuscitation equipment.”101
With the broad availability of mobile technology in LMICs,
there are increasing opportunities for mobile apps to improve
training of healthcare providers, for example, as a mode for
con-tinued medical education or to assistance with resuscitation
algo-rithms.102 In addition, the use of telemedicine can be beneficial
for LMICs, both for improved access to basic and subspecialty care and to promote learning and professional development.103
The global community can help by supporting country-led processes of reform and capacity building in education and by helping to create a stronger evidence base that contributes to cross-country learning.
Critical Illness During Public Health Emergencies
As past H1N1 influenza, severe acute respiratory syndrome, and Ebola outbreaks have clearly illustrated, improved preventive and disease surveillance strategies are necessary in LMICs, but also coordinated emergency and critical care resources are critical for saving lives during epidemics Globally, increasing urbanization, ease of travel, natural disasters, and regional war and conflict in-crease the risk of infectious outbreaks and need for critical care resources for potentially large numbers of seriously ill patients within a short period of time.104 Mass critical care preparedness in resource-limited settings is only recently being more systematically addressed.105 Use of technology to identify and communicate outbreaks may limit the impact of outbreaks and facilitate triage
to critical care resource locations.106 , 107 Further, an international consensus statement emphasizes the need to develop resilient
Trang 2CHAPTER 8 Challenges of Pediatric Critical Care in Resource-Poor Settings
healthcare systems to prepare for disaster and mass critical care
preparedness in resource-poor settings.108 Recommendations
in-clude strengthening the primary care, basic emergency care, and
public health systems and building critical care capacity in the
fields with the highest burden of disease—such as surgery,
obstet-rics, internal medicine, and pediatrics.108 District- and
regional-level health centers should develop at least a minimal regional-level of
critical care Therefore, to improve capacity building and quality
of care at district hospitals, performance improvement activities
should be instituted Prehospital care and transport of the
criti-cally ill could be improved through community-level education of
medical and nonmedical laypersons Highlighting
implementa-tion of these ideas, regional capacity building, emergency
pre-paredness training, and other public health efforts to improve
future response to outbreaks were recently described for West
African nations affected by Ebola.109
How to Develop an ICU in Low- to
Middle-Income Countries
Organizing a PICU in resource-poor settings is associated with
many challenges necessitating appropriate planning and proper
utilization of limited available resources The building blocks of
pediatric critical care services in any setting comprise specialized
training of healthcare professionals, including nursing staff, in
terms of knowledge, skills and teamwork, resource-appropriate
equipment selection, and adequate space for each patient Also
key is support of administration and leaders for logistics and
ap-propriate settings to provide services.30
Team-based training is essential for the success of intensive
care programs The aim should be to master the basic skills and
knowledge essential for pediatric critical care, such as resuscitation
skills, with effective communication among team members
Sim-ulation-based training has been shown to reinforce skills and
teamwork, improving outcomes, and is feasible in LMICs.14 , 30 , 61
The bed space as per PICU guidelines in HICs may not be
feasible in LMICs because of lack of infrastructure and
man-power Judicious use of space is needed for appropriate care of
high patient burden and to prevent cross-infection at the same
time Low-cost substitutes for expensive equipment may be used
as appropriate and preferably with locally available technological
services.30 , 61 , 110
As mentioned earlier, in order to improve outcomes and
judi-cious use of resources, it is important to establish patient selection
criteria for admission and discharge for every PICU along with
policies for end-of-life care decisions.111 Other key important
as-pects in PICU development in LMICs are to have (1) infection
control policies, (2) continuous supply of consumable items and
medications, (3) laboratory and radiology support, and (4) data
collection systems for measurement of PICU outcomes and
com-plications.111 The success of an intensive care program depends on
early recognition, timely referral, safe transport, good triage, and
emergency care Hence, it is important to strengthen these aspects
of care at the community level as well as improving emergency
services.30
Importance of Critical Care Research in Limited
Resource Settings
A large majority of published critical care research occurs in
HICs However, research findings in HICs may not directly
trans-late into improved outcomes in LRSs Recent breakthroughs in
pediatric resuscitation and critical care interventions in research programs conducted in LRSs have impacted clinical care in the following conditions: severe sepsis, in terms of fluid management; the benefits of early norepinephrine in patients with vasodilatory septic shock; the increased risk of dopamine (vs epinephrine) as
a first-line vasoactive agent in fluid refractory septic shock; and insights into the pathophysiology of cerebral malaria that in-formed an active clinical trial.112–118
There continues to be a vital need for investment in quality research programs that serve the unique needs of these children,
as the limited evidence in this field hinders effective and efficient care and advocacy for resources.10 , 61 Reasons for this gap in evi-dence include lack of funding; lack of local critical care providers, researchers, and research staff; lack of academic mentorship, infra-structure, and training to do research; and barriers to producing publishable research.119 Additionally, establishing research net-works in LRSs should be explored to leverage resources to support training, science quality, and capacity to accomplish more than would be done by individuals.
The research agenda should prioritize increasing evidence re-garding critical illness epidemiology and its outcomes in LRSs A more accurate estimate of the potential lives saved through critical care would serve to prove its role in healthcare systems in re-source-poor settings.18 Efficacy must be measured and validated for critical care interventions, with limited resources targeted to those practices that save lives, time, and resources Dissemination
of evidence and experience from successes and failures could help accelerate the pace of critical care infrastructure improvements Data on critical care capacity and access to both critical care re-sources and healthcare professionals are essential for health system planning but generally are lacking for pediatrics.
Recognizing that implementation of clinical care guidelines created using evidence from and for critical care provided in higher-resources settings may not be feasible, efforts should be made to generate and evaluate critical care guidelines for LRSs, especially for common conditions such as sepsis and coma.29 , 120
Cost-effectiveness analyses of current and proposed critical care practices need to be emphasized.61 Patient triage and clinical research would benefit from simple severity of illness scoring systems adapted and validated for resource-poor settings.
With increased survival from pediatric critical illness has come the realization of post-ICU sequelae and late mortality and thus the need for services to support continued recovery from critical illness and successful community reintegration For example, children admitted to the hospital in Uganda with infections had
a 4.9% increased risk of mortality in the first 6 months following discharge.121 Further, in severely malnourished Bangladeshi chil-dren initially treated in the PICU for severe pneumonia, postdis-charge (3 months) mortality was 8.6%.122 Identifying risk factors
of children at high risk or morbidity and late mortality before hospital discharge and providing effective interventions should be another research priority.
Low-cost critical care technology, such as noninvasive positive-pressure ventilation, is much needed to support critical care in LRSs Locally available, ubiquitous technology such as cell phones should be used to enable better healthcare seeking and delivery and solve clinical challenges While mobile apps for critical care and resuscitation are becoming available, there is significant need for quality control.123 , 124 Technology development must be tightly woven into solving implementation challenges that result from not only technology cost and availability but also complexity of the political, social, and professional systems in LMICs.120
Trang 358 SECTION I Pediatric Critical Care: The Discipline
Key References
Argent AC, Ahrens J, Morrow BM, et al Pediatric intensive care in South
Africa: an account of making optimum use of limited resources at the
Red Cross War Memorial Children’s Hospital Pediatr Crit Care Med
2014;15:7-14
Argent AC Considerations for assessing the appropriateness of
high-cost pediatric care in low-income regions Front Pediatr 2018;
6:68
Child GBD, Adolescent Health C, Reiner Jr RC, et al Diseases, injuries,
and risk factors in child and adolescent health, 1990 to 2017: findings
from the global burden of diseases, injuries, and risk factors 2017
study JAMA Pediatr 2019:e190337.
English M, Gathara D, Mwinga S, et al Adoption of recommended
practices and basic technologies in a low-income setting Arch Dis
Child 2014;99:452-456.
Opiyo N, English M In-service training for health professionals to
im-prove care of seriously ill newborns and children in low-income
countries Cochrane Database Syst Rev 2015;5:CD007071.
Sankar J, Ismail J, Sankar MJ, C PS, Meena RS Fluid bolus over 15-20 versus 5-10 minutes each in the first hour of resuscitation in children
with septic shock: a randomized controlled trial Pediatr Crit Care Med 2017;18:e435-e445.
Shann F Role of intensive care in countries with a high child mortality
rate Pediatr Crit Care Med 2011;12:114-115.
Slusher TM, Kiragu AW, Day LT, et al Pediatric critical care in
resource-limited settings-overview and lessons learned Front Pediatr 2018;6:49.
von Saint Andre-von Arnim AO, Attebery J, Kortz TB, et al Challenges and priorities for pediatric critical care clinician-researchers in low-
and middle-income countries Front Pediatr 2017;5:277.
Wilmshurst JM, Morrow B, du Preez A, Githanga D, Kennedy N, Zar HJ The African pediatric fellowship program: training in Africa for Africans
Pediatrics 2016;137(1)
Wilson PT, Baiden F, Brooks JC, et al Continuous positive airway pressure for children with undifferentiated respiratory distress in Ghana: an
open-label, cluster, crossover trial Lancet Glob Health 2017;5:e615-e623. The full reference list for this chapter is available at ExpertConsult.com
Trang 4References
1 Databank Agriculture & Rural Development https://data.worldbank
org/indicator
2 Child GBD, Adolescent Health C, Reiner Jr RC, et al Diseases,
injuries, and risk factors in child and adolescent health, 1990 to
2017: findings from the global burden of diseases, injuries, and risk
factors 2017 study JAMA Pediatr 2019;173(6):e190337.
3 The World Bank The World by Income and Region 2019 https://
datatopics.worldbank.org/world-development-indicators/the-world-by-income-and-region.html
4 Global burden of disease compare https://vizhub.healthdata.org/
gbd-compare/
5 Kissoon N, Argent A, Devictor D, et al World Federation of
Pedi-atric Intensive and Critical Care Societies-its global agenda Pediatr
Crit Care Med 2009;10:597-600.
6 Global Burden of Disease Study 2017 Institute for Health Metrics
and Evaluation (IHME) 2018
http://ghdx.healthdata.org/gbd-re-sults-tool
7 Collaborators GBDCM Global, regional, national, and selected
subnational levels of stillbirths, neonatal, infant, and under-5
mor-tality, 1980-2015: a systematic analysis for the Global Burden of
Disease Study 2015 Lancet 2016;388:1725-1774.
8 UNICEF Data: Monitoring the situation of children and women
Child Survival and the SDGs
https://data.unicef.org/topic/child-survival/child-survival-sdgs/
9 Children ACfHoWa Accountability for Women’s and Children’s
Health Geneva: The World Health Organization; 2014.
10 Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD Critical care
and the global burden of critical illness in adults Lancet 2010;376:
1339-1346
11 2018 World Population Data Sheet 2018 http://www.prb.org
12 Mendsaikhan N, Begzjav T, Lundeg G, Dunser MW The
epidemiol-ogy and outcome of critical illness in Mongolia: A multicenter,
prospective, observational cohort study Int J Crit Illn Inj Sci 2016;6:
103-108
13 Dunser MW, Baelani I, Ganbold L A review and analysis of
inten-sive care medicine in the least developed countries Crit Care Med
2006;34:1234-1242
14 Murthy S, Adhikari NK Global health care of the critically ill in
low-resource settings Ann Am Thorac Soc 2013;10:509-513.
15 Murray CJ, Lopez AD Measuring the global burden of disease
N Engl J Med 2013;369:448-457.
16 Annez PC An Agenda for Research on Urbanization in Developing
Countries: A Summary of Findings From a Scoping Exercise Geneva:
The World Bank; 2010
17 Adhikari NK, Rubenfeld GD Worldwide demand for critical care
Curr Opin Crit Care 2011;17:620-625.
18 Murthy SS, Adhikari KJ Critical Care in Low-Resource Settings New
York: Springer Science1Business; 2014
19 Shann F Role of intensive care in countries with a high child
mortal-ity rate Pediatr Crit Care Med 2011;12:114-115.
20 Baker T Critical care in low-income countries Trop Med Int Health
2009;14:143-148
21 Duke T, Tamburlini G, Silimperi D, Paediatric Quality Care G
Improving the quality of paediatric care in peripheral hospitals in
developing countries Arch Dis Child 2003;88:563-565.
22 Reyburn H, Mwakasungula E, Chonya S, et al Clinical assessment
and treatment in paediatric wards in the north-east of the United
Republic of Tanzania Bull World Health Organ 2008;86:132-139.
23 Nolan T, Angos P, Cunha AJ, et al Quality of hospital care for seriously
ill children in less-developed countries Lancet 2001;357:106-110.
24 English MLC, Ngugi I, Smith PC The District Hospital Chapter 65
Disease Control Priorities in Developing Countries Washington DC:
World Bank; 2006:1211-1228
25 English M, Esamai F, Wasunna A, et al Assessment of inpatient
paediatric care in first referral level hospitals in 13 districts in Kenya
Lancet 2004;363:1948-1953.
26 Gathara D, Opiyo N, Wagai J, et al Quality of hospital care for sick newborns and severely malnourished children in Kenya: a two-year
descriptive study in 8 hospitals BMC Health Serv Res 2011;11:307.
27 Turner EL, Nielsen KR, Jamal S, von Saint André-von Arnim A, Musa NL A review of pediatric critical care in resource-limited settings:
a look at past, present and future directions Front Pediatr 2016;4:5
28 Friberg IK, Kinney MV, Lawn JE, et al Sub-Saharan Africa’s moth-ers, newborns, and children: how many lives could be saved with
targeted health interventions? PLoS Med 2010;7:e1000295.
29 Dunser MW, Festic E, Dondorp A, et al Recommendations for
sepsis management in resource-limited settings Intensive Care Med
2012;38:557-574
30 Slusher TM, Kiragu AW, Day LT, et al Pediatric critical care in
re-source-limited settings-overview and lessons learned Front Pediatr
2018;6:49
31 Tiska MA, Adu-Ampofo M, Boakye G, Tuuli L, Mock CN A model
of prehospital trauma training for lay persons devised in Africa
Emerg Med J 2004;21:237-239.
32 African Neonatal Sepsis Trial Group, Tshefu A, Lokangaka A, et al Simplified antibiotic regimens compared with injectable procaine benzylpenicillin plus gentamicin for treatment of neonates and young infants with clinical signs of possible serious bacterial infec-tion when referral is not possible: a randomised, open-label,
equiva-lence trial Lancet 2015;385:1767-1776.
33 Baqui AH, Arifeen SE, Williams EK, et al Effectiveness of home-based management of newborn infections by community health
workers in rural Bangladesh Pediatr Infect Dis J 2009;28:304-310.
34 English M, Ntoburi S, Wagai J, et al An intervention to improve paediatric and newborn care in Kenyan district hospitals:
under-standing the context Implement Sci 2009;4:42.
35 Ayieko P, Ntoburi S, Wagai J, et al A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan
district hospitals: a cluster randomised trial PLoS Med 2011;8:e1001018.
36 Molyneux E, Ahmad S, Robertson A Improved triage and emer-gency care for children reduces inpatient mortality in a
resource-constrained setting Bull World Health Organ 2006;84:314-319.
37 Molyneux E Emergency care for children in resource-constrained
countries Trans R Soc Trop Med Hyg 2009;103:11-15.
38 Ashraf H, Mahmud R, Alam NH, et al Randomized controlled trial
of day care versus hospital care of severe pneumonia in Bangladesh
Pediatrics 2010;126:e807-e815.
39 Addo-Yobo E, Anh DD, El-Sayed HF, et al Outpatient treatment of children with severe pneumonia with oral amoxicillin in four
coun-tries: the MASS study Trop Med Int Health 2011;16:995-1006.
40 Duke T, Wandi F, Jonathan M, et al Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua
New Guinea Lancet 2008;372:1328-1333.
41 Bassiouny MR, Gupta A, el Bualy M Nasal continuous positive airway pressure in the treatment of respiratory distress syndrome: an
experience from a developing country J Trop Pediatr 1994;40:
341-344
42 Pieper CH, Smith J, Maree D, Pohl FC Is nCPAP of value in extreme
preterms with no access to neonatal intensive care? J Trop Pediatr
2003;49:148-152
43 Tapia JL, Urzua S, Bancalari A, et al Randomized trial of early bubble continuous positive airway pressure for very low birth weight
infants J Pediatr 2012;161:75-80.e1.
44 Tagare A, Kadam S, Vaidya U, Pandit A, Patole S Bubble CPAP versus ventilator CPAP in preterm neonates with early onset
respira-tory distress—a randomized controlled trial J Trop Pediatr
2013;59:113-119
45 van den Heuvel M, Blencowe H, Mittermayer K, et al Introduction
of bubble CPAP in a teaching hospital in Malawi Ann Trop Paediatr
2011;31:59-65
46 Koyamaibole L, Kado J, Qovu JD, Colquhoun S, Duke T An evalu-ation of bubble-CPAP in a neonatal unit in a developing country:
effective respiratory support that can be applied by nurses J Trop Pediatr 2006;52:249-253.
Trang 547 Wilson PT, Morris MC, Biagas KV, Otupiri E, Moresky RT A
randomized clinical trial evaluating nasal continuous positive airway
pressure for acute respiratory distress in a developing country J Pediatr
2013;162:988-992
48 Wilson PT, Baiden F, Brooks JC, et al Continuous positive airway
pressure for children with undifferentiated respiratory distress in
Ghana: an open-label, cluster, crossover trial Lancet Glob Health
2017;5:e615-e623
49 Argent AC Considerations for assessing the appropriateness of
high-cost pediatric care in low-income regions Front Pediatr 2018;6:68.
50 Kulkarni AP, Divatia JV A prospective audit of costs of intensive care
in cancer patients in India Indian J Crit Care Med 2013;17:
292-297
51 Miljeteig I, Johansson KA, Sayeed SA, Norheim OF End-of-life
decisions as bedside rationing An ethical analysis of life support
re-strictions in an Indian neonatal unit J Med Ethics 2010;36:473-478.
52 Beerenahally TS No free bed with ventilator: experience of a public
health specialist Indian J Med Ethics 2017;2:56-57.
53 Firth P, Ttendo S Intensive care in low-income countries—a critical
need N Engl J Med 2012;367:1974-1976.
54 Rezzonico R, Caccamo LM, Manfredini V, et al Impact of the
sys-tematic introduction of low-cost bubble nasal CPAP in a NICU of
a developing country: a prospective pre- and post-intervention study
BMC Pediatr 2015;15:26.
55 Mukhtar B, Siddiqui NR, Haque A Clinical Characteristics and
Immediate-Outcome of Children Mechanically Ventilated in PICU
of Pakistan Pak J Med Sci 2014;30:927-930.
56 Khanal A, Sharma A, Basnet S Current State of Pediatric Intensive
Care and High Dependency Care in Nepal Pediatr Crit Care Med
2016;17:1032-1040
57 Cubro H, Somun-Kapetanovic R, Thiery G, Talmor D, Gajic O
Cost effectiveness of intensive care in a low resource setting: A
pro-spective cohort of medical critically ill patients World J Crit Care
Med 2016;5:150-164.
58 Caney S Justice Beyond Borders Oxford: Oxford University Press; 2005.
59 Engelhardt Jr HT Critical care: why there is no global bioethics
Curr Opin Crit Care 2005;11:605-609.
60 Murthy S, Leligdowicz A, Adhikari NK Intensive care unit capacity
in low-income countries: a systematic review PLoS One 2015;10:
e0116949
61 Riviello ED, Letchford S, Achieng L, Newton MW Critical care in
resource-poor settings: lessons learned and future directions Crit
Care Med 2011;39:860-867.
62 Baker T Pediatric emergency and critical care in low-income
coun-tries Paediatr Anaesth 2009;19:23-27.
63 Rodgers A, Ezzati M, Vander Hoorn S, et al Distribution of major
health risks: findings from the Global Burden of Disease study PLoS
Med 2004;1:e27.
64 Ballot DE, Davies VA, Cooper PA, Chirwa T, Argent A, Mer M
Retrospective cross-sectional review of survival rates in critically ill
children admitted to a combined paediatric/neonatal intensive care
unit in Johannesburg, South Africa, 2013-2015 BMJ Open 2016;
6:e010850
65 Argent AC, Ahrens J, Morrow BM, et al Pediatric intensive care in
South Africa: an account of making optimum use of limited
re-sources at the Red Cross War Memorial Children’s Hospital* Pediatr
Crit Care Med 2014;15:7-14.
66 Xu K SP, Evans D Health Financing and Access to Effective
Interven-tions World Health Report 2010 Background Paper No 8 Geneva:
World Health Organization; 2010
67 Lewin S, Lavis JN, Oxman AD, et al Supporting the delivery of
cost-effective interventions in primary health-care systems in
low-income and middle-low-income countries: an overview of systematic reviews
Lancet 2008;372:928-939.
68 Ayieko P, Ogero M, Makone B, et al Characteristics of admissions
and variations in the use of basic investigations, treatments and
outcomes in Kenyan hospitals within a new Clinical Information
Network Arch Dis Child 2016;101:223-229.
69 Kihuba E, Gathara D, Mwinga S, et al Assessing the ability of health information systems in hospitals to support
evidence-in-formed decisions in Kenya Glob Health Action 2014;7:24859.
70 Gachau S, Ayieko P, Gathara D, et al Does audit and feedback im-prove the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in
Kenya BMJ Glob Health 2017;2:e000468.
71 Akech S, Ayieko P, Irimu G, Stepniewska K, English M, Clinical Information Network a Magnitude and pattern of improvement in processes of care for hospitalised children with diarrhoea and
dehy-dration in Kenyan hospitals participating in a clinical network Trop Med Int Health 2019;24:73-80.
72 English M, Nzinga J, Mbindyo P, Ayieko P, Irimu G, Mbaabu L Explaining the effects of a multifaceted intervention to improve in-patient care in rural Kenyan hospitals—interpretation based on ret-rospective examination of data from participant observation,
quan-titative and qualitative studies Implement Sci 2011;6:124.
73 World Health Organization Systems Thinking for Health System Strengthening Geneva: World Health Organization; 2009.
74 Morel CM, Lauer JA, Evans DB Cost effectiveness analysis of
strategies to combat malaria in developing countries BMJ 2005;
331:1299
75 Balabanova D, Mills A, Conteh L, et al Good Health at Low Cost
25 years on: lessons for the future of health systems strengthening
Lancet 2013;381:2118-2133.
76 WHO The World Health Report 2006 - Working Together for Health
Geneva: WHO Press; 2006
77 Hongoro C, McPake B How to bridge the gap in human resources
for health Lancet 2004;364:1451-1456.
78 Celletti F, Reynolds TA, Wright A, Stoertz A, Dayrit M Educating
a new generation of doctors to improve the health of populations in
low- and middle-income countries PLoS Med 2011;8:e1001108.
79 Mullan F, Frehywot S, Omaswa F, et al Medical schools in sub-
Saharan Africa Lancet 2011;377:1113-1121.
80 Kolars JC, Cahill K, Donkor P, et al Perspective: partnering for medical education in Sub-Saharan Africa: seeking the evidence for
effective collaborations Acad Med 2012;87:216-220.
81 Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D, Dit-lopo P Motivation and retention of health workers in developing
countries: a systematic review BMC Health Serv Res 2008;8:247.
82 Cancedda C, Farmer PE, Kerry V, et al Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income
Coun-tries: Frameworks, Challenges, and Best Practices PLoS Med
2015;12:e1001840
83 Canarie MF, Shenoi AN Teaching the Principles of Pediatric Critical Care to Non-Intensivists in Resource Limited Settings: Challenges
and Opportunities Front Pediatr 2018;6:44.
84 Wilmshurst JM, Morrow B, du Preez A, Githanga D, Kennedy N, Zar HJ The African pediatric fellowship program: training in Africa
for Africans Pediatrics 2016;137(1)
85 Pediatric Emergency and Critical Care Kenya www.pecc-kenya.org
86 Rid A, Emanuel EJ Why should high-income countries help
com-bat Ebola? JAMA 2014;312:1297-1298.
87 Mormina M, Pinder S A conceptual framework for training of
trainers (ToT) interventions in global health Global Health
2018;14:100
88 Barasa EW, Ayieko P, Cleary S, English M A multifaceted interven-tion to improve the quality of care of children in district hospitals in
Kenya: a cost-effectiveness analysis PLoS Med 2012;9:e1001238.
89 Wright SW, Steenhoff AP, Elci O, et al Impact of contextualized pediatric resuscitation training on pediatric healthcare providers in
Botswana Resuscitation 2015;88:57-62.
90 Joynt GM, Zimmerman J, Li TST, Gomersall CD A systematic review of short courses for nonspecialist education in intensive care
J Crit Care 2011;26:533 e1-e10.
91 Meaney PA, Sutton RM, Tsima B, et al Training hospital providers
in basic CPR skills in Botswana: acquisition, retention and impact
of novel training techniques Resuscitation 2012;83:1484-1490.