Behind the Paper: The Children’s Hospitals in Africa Mapping Project (CHAMP) survey

In this post, we talk to the authors of the recently published paper, The Children’s Hospitals in Africa Mapping Project (CHAMP) survey: Facilities, equipment, supplies, infrastructure, and capacity to respond to emergencies by Vinayak Bhardwaj, Lawrence R. Stanberry, Philip LaRussa, Wilmot James, Maitry Mahida, Aimable Kanyamuhunga, Atnafu Mekonnen Tekleab, Augustine Omoigberale, Crispen Ngwenya, David Musorewegomo, Dipesalema Joel, Ezekiel Mupere, Fidelis Ewenitie Eki-Udoko, Hannah Bousquet, Heloise Buys, Hilda Angela Mujuru, Ike Oluwa Lagunju, Irene Marete, Jethro Zawolo, Jonathan Kaunda Mwansa, Joseph Tawanda Chava, Maima Kawah Baysah, Mildred Anyango Mudany, Nancy Biyeah Yang Ngum,Nellie V. T. Bell,One Bayani, Pauline Samia, Ruth Nduati, Sam Miti, Schyler Zane Grodman, Thembisile Dintle Mosalakatane, Workeabeba Abebe, and Ashraf Coovadia.

What led you to decide on this research question?

In early 2018, following the Zika epidemic in the Americas, we began discussing how prepared the world was to address the special needs of its 2.3 billion children in the event of a pandemic or a catastrophic event.  In our view neither the World Health Organization International Health Regulations 2005 nor the Joint External Evaluation (JEE) tool, addressed the needs of children. Our original goal was to develop a survey to assess the readiness of healthcare facilities that care for large numbers of children to respond to biological, chemical or nuclear threats. During a meeting convened at the Columbia Global Center in Nairobi in August 2018, our collaborators proposed that the focus of the study be broadened to include other topics important in assuring children received the highest quality of care possible.

Could you talk us through how you designed your study?

At the 2018 Nairobi meeting healthcare leaders from 13 African countries sat to discuss and co-design a survey that could assess how well hospitals were prepared to handle emergencies affecting children. This took place over a two-day workshop. Together, we shaped a definition of what a “children’s hospital” means in the African context and added broader elements like nutrition and quality of care. After testing the tool at a site in South Africa, we refined it and rolled it out more widely. To complement the site-assessment survey, one of the principal investigators—either from Columbia University or the University of the Witwatersrand—visited each hospital in person to tour the facilities.

The Columbia University team – Professor Larry Stanberry, Professor Wilmot James and Professor Phillip Larussa

What was important for your team as you created the study team?

The initial hope was that the study would evolve in a way that the investigators group would stay together to implement interventions to address the issues raised by the surveys, in a way the clinical trials network, IMPAACT (International Maternal Pediatric Adolescent AIDS Clinical Trials) did for HIV care.

What was critical to getting the buy-in of all representatives at the Nairobi meeting was the view that the survey was not only a useful global tool but one that could assist individual sites with their own advocacy efforts.

There was also an effort to be as inclusive of as many sites as possible in Africa to be representative of the continent.

What challenges did you encounter during your study?

The major challenge was the COVID-19 pandemic. Twenty-four hospitals agreed to participate but four were unable to finish the survey before the pandemic brought an abrupt end to the data collection phase of the study.

What did you find most striking about your results? 

What stood out for the team was the level of commitment and resolve by healthcare teams in all centers in delivering services to children in the face of such severe resource constraints and challenges.  There was a palpable sense of wanting to do more but for the lack of resources.

The severity of the lack of resources, however, was itself a striking result of our analysis – surprising even those of us who work in these environments.  From the low availability of staffing for emergencies (presumably worse since the COVID-19 pandemic), the inability to perform what might be considered basic surgical services in developed countries, to the sheer lack of bed space, resulting in more than one baby per crib (thus exacerbating cross-infection risk), such shortages were more common than we initially envisaged.

There were glaring disconnects between first class technology and expertise (e.g. the intubation and ventilation of premature neonates) in use but developing world challenges such as the lack of uninterrupted power supply or running water. The need to put more than one baby in a crib risking cross infection and outbreaks was unfortunately not uncommon.

This exercise in itself had inherent value for the teams conducting the survey at their sites by allowing them to take a step back and look at what could be done differently.

How will this research be used?

We plan to share the results of this study. both published and unpublished data, with a range of stakeholders who have an interest in the health of children in Africa. This includes government health ministries, non-governmental agencies, global institutions such as WHO and UNICEF, and philanthropies. We see this work as part of an advocacy effort to ensure that children’s hospitals are well resourced and that minimum resource benchmarks are established. Further we hope this research serves as a baseline for future work and that future studies will take advantage of the network of colleagues who formed the CHAMP study team.

Why did you choose PLOS Global Public Health as a venue for your article?

PLOS Global Public Health was our first choice for several reasons; (1) its wide global readership, (2) we wanted all those involved in the research to be listed authors rather than being recognized as part of a working group and PGPH does not have a limit on number of authors, (3) our data set was very large and the lack of a word limit was critical, (4) we wished to make the CHAMP survey available to the public and that was possible with PLOS Global Public Health.

What further research questions need to be addressed in this area?

There are a number of questions that need to be explored in this area. Firstly, what was sampled for this study were the large mostly referral or central teaching hospitals. These were expected to be the better resourced centres. What is unknown is how the rest of the hospitals in each country fare with respect to children’s services. Next this study was really a snapshot of what these services looked like in 2018/2019 pre-COVID. The question of what COVID-19 did to these services and perhaps by extrapolation to all paediatric services in the county has to be asked and hopefully answered by a follow up study. Added to this is the current funding crisis with the withdrawal of USAID and other funders that played a significant role in shoring up healthcare systems in sub-Saharan Africa. As a critical first step, it would be important to understand how governments can fill the gap in funding. Further tools and analyses could help support identifying and developing cost-effective programs that deliver maximum health impact at the lowest cost, allowing health systems to prioritise how to sustain and expand life-saving services at children’s health facilities.

Through the lens of what services children are receiving in these hospitals, the assessment of whether training programmes in these countries are aligned to the needs and whether they are fit for purpose. What cadres of healthcare providers are needed and what are the projected needs of all such professionals over the next 10-20 years. This, once again, requires a look at the funding requirements of national health budgets to meet these needs.

Finally, this network is well poised to look at how resilient these services are in the face of climate change and both the chronic and acute challenges this poses.