African centres for Service Delivery Research

The CLAHRC WM Director returned yesterday from a three week trip to African centres for Service Delivery Research (see here for a map).* He visited:

The launch of the CHSSRD
The launch of the CHSSRD

CLAHRC WM is establishing collaborations with these centres of excellence in South and East Africa. Some of the health problems that African centres are tackling are very different from those in the West Midlands (malaria and infant malnutrition), while others are similar (type 2 diabetes and hypertension). However, although the specific problems may vary, at the generic level there is startling similarity in objectives (improving access, identifying problems before harm is done, improving implementation of care standards and so on – examples are given in Table 1). Likewise the methodological issues in carrying out evaluations are, if not identical, then very similar across continents. These observations reinforce the idea that we have a lot to learn from each other and that the North-South divide is a barrier more in our minds and on maps than in the problems we face and methods used to address them.

One very generic issue concerns the question of whether hospitals and hospital departments fail in the specific or in the general – that is to say are rates of adherence to the tenets of good practice correlated within hospitals and their departments? This is a crucial issue for managers, since if they are only very poorly correlated, as found in some studies,[1] [2] then efforts at improvement may need to be focussed on each standard, one at a time. However, if they are strongly correlated, then a generic approach might get more purchase. The issue is also important scientifically, since high correlation within hospitals/departments reduces precision in comparative studies (the so-called “design effect”) meaning that larger numbers of clusters are needed to achieve a given level of statistical power. CLAHRC WM is proposing to investigate this issue in primary and secondary research studies. This project will be greatly enriched by collaboration across high- and low-income countries, allowing the role of context to be more thoroughly explored.

We would be grateful for comments from readers, along with enquiries about future collaborations, which can be made “without prejudice.”

*As an aside, he also completed the gruelling 109km Cape Argus Cycle Tour for the Amy Biehl Foundation, riding alongside famous cricketer Allan Lamb, and finishing the course in 4:21:51 despite dealing with a late puncture and headwinds of up to 45km/h.

Table 1

Topic CLAHRC WM
Example
CLAHRC Africa
Example
Triage Surges in demand for admission to labour ward Sick children may wait up to 3 hours to be seen in long queues outside health facilities
Workforce training and continuing
education
Physician assistants, nurse and doctors Clinical officers, nurses and doctors
Case-finding Undetected high-risk in the community Nutritional deficiency and hypertension in villages and urban
informal settlements
Implementation of
effective care
– identifying and then overcoming barriers
Uptake of home haemodialysis /
improving holistic trauma care for elderly people
Management of adult
diabetes and paediatric emergencies
Cost-effectiveness of Service Delivery Interventions ePrescribing systems and increasing
consultant cover over weekends
Increasing high-
dependency bed
availability under
different constraints
Non-allopathic care for mental illness Providing a platform (“YouthSpace”) for young adults with
mental illness
Exploring the role of the traditional healer

–Richard Lilford, Director of CLAHRC WM

References

[1] Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals — the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.

[2] Wilson B, Thornton JG, Hewison J, Lilford RJ, Watt I,  Braunholtz D, et al. The Leeds University Maternity Audit Project. Int J Qual Health Care. 2002;14:175-81.

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