Implementing locally appropriate guidelines and training to improve care of serious illness in Kenyan hospitals: a story of scaling-up (and down and left and right)

Inadequate health systems are now widely recognised as major barriers to improved newborn and child survival and achieving Millennium Development Goal 4 that calls for a two-thirds reduction in under 5 mortality in low-income settings.1 A key challenge of the coming decade is thus to strengthen health systems and ‘scale-up’ delivery of safe, accessible and high quality care.2,–,4 The required interventions are often divided up into ‘essential packages’, each with their own training materials and dedicated training courses. Examples include essential neonatal care, essential obstetric care, malaria case management, case management of severe malnutrition and management of the HIV infected child. Reported examples of successful scaling-up of such packages are usually drawn from large, internationally well-funded programmes in fields such as HIV.5 In contrast, support for widespread implementation of cross-cutting interventions such as WHO/UNICEF's Integrated Management of Childhood Illnesses can be half-hearted even if the approach is formally adopted at policy level.6 7 For care of the seriously ill child, in theory concentrated in rural hospitals as a result of referral, a holistic approach, identifying and managing all needs given the available resources, is intuitively sensible rather than focusing thinking and training on only malaria, or only HIV or only severe malnutrition.8 Such thinking prompted development of WHO's Emergency Triage Assessment and Treatment (ETAT) training programme,9 designed with a similar philosophy to emergency care courses aimed at higher income settings (eg, European Paediatric Life Support, EPLS). However, work indicating outdated, poor quality of case management of serious illness10 11 revealed a need for knowledge …