Engaging stakeholders in embedded newborn health services/systems research in Kenya; a continuous process involving multiple actors.

The HIGH-Q Programme 2020–2025

The HIGH-Q programme, implemented in Kenya, is a partnership between the Kenya Medical Research Institute (KEMRI)-Wellcome Trust research programme, the University of Oxford, the Kenya Paediatric Research Consortium, the London School of Hygiene & Tropical Medicine and the County Departments of Health. Running from October 2020 to September 2025, the HIGH-Q Programme of work comprises a co-designed, multi-disciplinary intervention and evaluation to study the effects on nurse-delivered care of a prospectively designed workforce intervention aimed at improving nurse staffing in select neonatal units in Kenya. The workforce intervention was built around and concurrent with a multi-country intervention programme known as Newborn Essential Solutions and Technologies (NEST360)¹⁸. The NEST360 technology intervention is implemented in a large subset of a network of county hospitals known as the Clinical Information Network (CIN) (See Box 1 for a summary of NEST360 and CIN); the HIGH-Q programme involved a smaller subset of these NEST360 sites.

The HIGH-Q programme has a specific focus on neonatal care in Kenyan hospitals. The programme is assessing how introducing additional workforce alongside the NEST360 technologies in Kenyan hospitals affects technology adoption and quality of care in light of known and substantial workforce deficits¹⁴. The Programme rationale was based on the assumption that adding technologies by themselves will improve quality and safety and that the available staff can successfully implement new technologies. However, this might not be the case; hence, the research focus on an improvement in staffing levels to assess more successful use of technologies as a way to improve care. Completed in July 2023, the specific workforce intervention aimed to increase nursing and ward assistant numbers in newborn units¹⁹. Specifically, the intervention involved the employment of three additional nurses and three ward assistants in each of the four-county hospital newborn units for 15 and 7 months respectively. Besides the technology introduction angle, additional nurses for the intervention were also considered. Sick newborns in NBUs require continuous monitoring and treatment, but low nurse-to-patient ratios compromise care and have been linked to an increase in mortality. While adding more skilled nurses could improve care quality by reducing missed tasks and strengthening teamwork, it remains a challenge due to underfunded health systems. Nurses also spend time on lower-skilled duties, such as cleaning equipment, changing linens and diapers, and assisting mothers with breastfeeding, tasks that could be delegated to ward assistants.

Salaries for these staff were paid by the HIGH-Q programme for the research period, but the staff were employed and line-managed by the hospitals. The other HIGH-Q objectives examine health workers and mothers’ experiences of newborn care, how to better support the delivery and integration of post-discharge care for families, the governance process of introducing technologies and service delivery innovations and infection prevention control in these newborn units. Primary data collection includes structured and unstructured observations of care and technology use and interviews with healthcare professionals (at all levels of the health system) and carers. Table 1 summarises HIGH-Q Programme work packages, research questions and methods. The Workforce intervention was assessed under work packages 1a and 1b.

In Kenya, health care is devolved from the national government to 47 semi-autonomous sub-national governments (commonly known as counties)²⁰. Under this governance arrangement, county governments have an executive, administrative and legislative mandate. From the early study planning stages for HIGH-Q, it was recognised that stakeholder engagement was needed at national, county, hospital and newborn unit levels, and should build upon and consider wider CIN and NEST360 activities, as well as any other research that might be ongoing at these sites during this period.

Synthesis and interpretation of learnings

To support our reflections of the impact of the Programme’s stakeholders’ activities, we have applied ideas from Kujala, Sachs, Leinonen, Heikkinen & Laude (2022) conceptual framework which proposes engagement activities to consist of moral, strategic, and pragmatic components²². Their framework is a response to what is observed by the paper as a fragmented approach to analysing stakeholder engagement which hampers research progress. The moral component involves considering the ethical dimensions of how the operations of an organisation affect individuals and groups rather than focusing on organizational interests. In the context of our research, we consider for example how to engage particularly marginalized stakeholders, how to ensure respectful interactions with all stakeholders, and how to ensure the research is made meaningful to diverse stakeholders. The strategic component is concerned with how managers distribute scarce resources among stakeholders in ways that ensure value creation for the organisation and the achievement of its objectives. In the context of our research for example we recognise that we have deliverables to ourselves and our funders with regards to quality of research and our contribution to knowledge. The pragmatic component could be seen as working across the moral and strategic components. Drawing on Chinyio and Akintoye (2008)²³ and Forsythe, Ellis, Edmundson et al. (2015)⁹, we considered these as pragmatic activities to build and sustain connections. Including employing negotiations, making trade-offs and adjusting to the practical requirements of stakeholders.

Under this approach to reflection, stakeholder engagement in the programme were assessed if they met the three goals of engagement of moral, strategic and pragmatic by analysing the element of the of Programme specific activities against the three components.

Developing an initial strategic plan to guide stakeholder engagement

During the proposal development and the programme’s setup phases, the investigators formulated an initial framework for engaging stakeholders. This framework encompassed engagement objectives, detailed stakeholder mapping, and the nature and content of engagement activities (Figure 1). The overall inter-related goals of stakeholder engagement were to contribute to 1) good quality science through inputs into study design, implementation and outputs; 2) ensuring ethical practice throughout the research process, and 3) maximising the uptake of research findings in policy and practice.

Figure 1. The HIGH-Q Community and Stakeholders’ engagement framework goals and the components of engagements.

The engagement framework covered a full spectrum of activities. At one end of the spectrum was deep engagement involving fewer people in more interactive ways. Activities include engaging stakeholders in consultative meetings to co-design elements of the research and get advice on the stakeholder engagement plan itself, as well as on how to conduct the research. At the other end of the spectrum are wider engagement activities aimed at reaching many people through inevitably less interactive activities. Examples include radio programmes, video outputs, newspaper articles and policy briefs.

At the heart of the engagement activities, and to advise on all activities, we set up international and national advisory expert groups with diverse types of expertise. The international expert group includes seven stakeholders with global health research experience and expertise in medical sociology, health economics, organisational analysis, health workforce and systems, infectious disease epidemiology, regional nursing policy and advocacy for nursing and maternal and child health.

The national expert group consists of eight individuals with representation from the national Ministry of Health, medical schools, medical and nursing professional communities, professional association regulators, and patient representative groups. These groups were consulted together at least annually supplemented by periodic interactions with members as needed.

The expert group contributed towards the study design. During early stages the research team received valuable input from the members of the expert group that helped research approaches and execution, for example on the sequence of additional nurses and ward assistant intervention we got valuable input that helped inform the intervention:

“I would rather add the nurses first and then add the assistants later. The nurses will be supervisors to the assistants, so it better that they are first orientated to enable them to be more useful. So that we can say the changes are due to the registered nurses” (NEG 1)

Implementing engagement across a complex and expanding range of stakeholders

The process of stakeholder identification using the stakeholder matrix yielded multiple stakeholders who included the national and county level policymakers, medical and nursing professional communities, professional association regulators, health managers at various levels of the health system, frontline healthcare workers in hospitals, and hospital patients, family members and patient representative groups. These stakeholders, especially those close to the research, were engaged throughout the HIGH-Q research process. based on our understanding of their needs, interests and concerns (Figure 2). Drawing on the International Association for Public Participation distinctions described above, we informed all stakeholders about key information to help them comprehend the research issues and support further engagement. We also involved representatives of all stakeholders (including research participants), to ensure their concerns were understood and considered in research activities and study learning. We consulted with representatives of many stakeholder groups to gather input regarding our plans, including through our advisory groups and had formal collaborations with stakeholder groups drawn from the counties and hospitals. We sought to ensure the research was as responsive as possible to stakeholders’ needs and priorities and would not have been able to proceed if gatekeepers such as regulators and county and hospital managers had not approved the study. Nevertheless, the final decision-making on the study details remained with the study team. In these ways, we were continuously balancing ethical, strategic and pragmatic elements of stakeholder engagement. For the workforce intervention level, the recruitment approach followed county procedures as described in a later section. At the NBU level, nurse managers were fully empowered to manage the duties and performance of additional nursing staff.

Figure 2. Presentation of multiple stakeholders engaged each with different interests.

As presented in Figure 3, there were three main observations from this work. First, the bulk and the backbone of stakeholder engagement focused on the four hospitals, especially on assessing the technology introduction and workforce enhancement effects on care, staff, and families. We were aware that the engagement of leadership and health workers is critically important and had planned an initial engagement with the county director of health followed by engagements down through the hospital hierarchy to newborn units. However, the workforce component significantly expanded the complexity of our engagement processes as outlined further in the following section.

Figure 3. A summary of the HIGH-Q Community and Stakeholders’ engagements against Programme milestones.

Our second observation is that we had to respond to field questions and realities with many informal or unplanned follow-up engagements or activities, in response to issues raised by the study teams or stakeholders. Examples include:

We observed that while some of these issues could be considered primarily practical, strategic, or moral, there were often interactions and interplays between the components. For example, having too many research staff on a ward had practical implications (difficult to collect data) and moral implications (disruption to routines of busy, often overwhelmed staff and to care of vulnerable children). Our third observation was that some stakeholder groups were more challenging to engage in terms of reaching them and achieving sustained involvement than others. For instance, our engagement with parents was primarily through interviews and observations, preceded by consent, and informal interactions. Linked to research governance, our study was subject to review and approval by the National Commission for Science, Technology, and Innovation (NACOSTI) and our international researchers were required to apply for and obtain research permits from the Immigration Department. Still, on research governance, we had quite a bit more interaction with nursing regulators/professional bodies such as the Nursing Council of Kenya (NCK) and the National Nursing Association of Kenya (NNAK). Our engagement with these regulatory institutions involved following all requirements at international, national, and local levels for initial approval and where necessary annual reports and renewal. At the data collection level, we reached out to a range of regulators of health research and technology to conduct interviews, with varying success.

As part of reaching out to an even wider audience, we plan to engage with teaching institutions and the media as part of the next phase of stakeholder engagement.

Different approaches and outcomes between counties with similar architecture

In the county structure in Kenya, there were several important officeholders to consider in any hospital-based engagements (See Box 2 on County Governments and the Departments of Health structure relevant to the study, adapted from the County Government Act, 2012²⁴ and the Transition to Devolved Government Act, 2012²⁵). In the HIGH-Q programme, the nature of the workforce intervention - with additional staff employed and managed by the county government - triggered a more complex set of engagements than is typically required for more observational or descriptive research. Figure 4 illustrates our original linear simple partnership plans in the centre. These morphed into many referral contacts, many people to talk to and get permission from and eventually the conversion of simple agreements into complex Memoranda of Understanding (MoU). To get permission and approval for this aspect of the research, we had to engage with chief officers, the county executive committee member, a county public service board, the county legal offices, the county secretary, and the governors. These engagements differed across counties, leading to differences in the ways additional staff were employed, despite the similarity in county hierarchical and administrative architecture.

Box 2. County Government and Departments of Health structure relevant to the study

Figure 4. A presentation of County and Hospital structure and the evolving engagement by the HIGH-Q Programme.

Other notable differences were in the engagement frequency and duration in the four counties to gain approvals and on other research-related events. Table 2 below presents quantitative data on the frequency and duration of engagement with different county officials in the pre-intervention (PRE I) period comprising 7 months, and during the intervention (DUR I) comprising 15 months. The pre-intervention period was before the MoU signing and the recruitment and deployment of additional staff. The intervention period consisted of deploying staff working in the units and data collection. The number of engagements in this period with county and hospital-level senior office holders ranged from 5 (County A) to 23 (County D). The combination of methods employed for engagement consisted of face-to-face, phone calls, email correspondence and letters. A majority of county and hospital executives were engaged directly and at varying durations (presented numerically in brackets and consisting of weeks of engagement from initial contact to sharing of findings) and frequencies (also presented numerically). Those closer to the intervention (the medical superintendents) were engaged multiple times, while those further from the intervention (the governors and the CECMs) less often.

The differences in engagement pathways between counties were reflected in MoU execution and recruitment of staff (Table 3). The pathways differences were a proactive incorporation of county stakeholders' input into the engagement process and consultations on how best to implement the study as partners. For example, as presented in Figure 4, the Programme agreement proposals were expanded and converted to MoUs to include additional clauses and signatories. We assessed MoU attributes according to the number of signatories, number of articles, and weeks from initiation to full execution. We see that County A added an extra clause on recruitment by the County Public Service Board (CPSB), and County B was directly coordinated by the county director of health (DoH) who worked closely with the County’s legal team to develop and sign a complex MoU with multiple clauses. The process at County B took double the time of Counties A and C, where the process was coordinated by the HIGH-Q team. The extra layer of engagement process involving the CPSB was an uncharted route before and presented tension, uncertainty with budgetary implications for advertisement in a national newspaper. However, these concerns were well mitigated with an efficient internal consultative process, strategy and open engagement with the Board. Still under recruitment, County B deployed recruited staff in other departments and utilised existing staff for the intervention. Though this was a noble initiative for sustainability. The Programme had to carefully relay this feedback to the newly recruited staff whose contract indicated they will work in NBUs and will be trained prior to deployment.

Our experiences underscored the importance of being able to be flexible and responsive in our engagement and study plans. Of note is that the entire process above was also complicated by routine job (re)postings and by national general elections. At the governor level, three of four governors and all the four Executive Committee members (CECMs) at the Department of Health in the four counties exited after the general elections, and in one of the counties, there were 3 different CECMs during the engagement period. All four Chief Officers at the Department of Health (COHs) left after the elections, although the County Directors of Health remained, and all hospitals registered a transition in the office of the medical superintendents during the engagement period. The first transition of medical superintendents happened only one month after the commencement of engagement at County C and the last a month before the end of the engagement period. These changes led to the need to regularly engage afresh, especially where the new office holders were closely involved in the implementation, such as medical superintendents. In County A&B the transition happened before the MOUs had even been signed.

Engagement for research feedback and study withdrawal

As illustrated in Figure 3, we undertook two cycles of research feedback at the four county hospitals during the engagement period, with further feedback and discussion of findings planned over the next 6–12 months.

The first research feedback meeting took place between November and December 2022, six months into the nursing workforce intervention and just before the introduction of ward assistants. The objective of this feedback was to give progress updates and preliminary research findings from the baseline survey. The findings were anonymized across all the four sites. The audience targeted included the medical superintendent, paediatrician, nursing leaders and various departmental staff. The feedback provided further opportunities for hospitals to understand the qualitative work and consenting process, and to promote discussion on aspects of care the hospitals were eager to improve. Stakeholders expressed being keen in future to have hospital-specific feedback.

The second set of feedback was given in December 2023 and February 2024, a year later, after completion of all the fieldwork, and following further analysis. Before feedback in each hospital, the research team spent considerable time preparing feedback data presentations and crafting appropriate messages to hospitals. Hospital-specific data were provided with comparative anonymized data from other hospitals. The NBU hospital teams were interested in discussing the clinical data but were also concerned about the withdrawal of intervention staff once the study was over.

In response to NBU team requests, and as part of the withdrawal plan from hospitals, we conducted an additional extensive set of engagements with county stakeholders at the departments of health in all four counties to explore the retention and absorption of intervention staff into the county workforce. We corresponded with all county and hospital executives previously involved in the study approval process - county secretary (County A) CECMS (all counties) CoH (County A &C) DoH (all counties) and medical superintendents (all counties). Our engagement involved a brief highlight of existing partnership and contractual arrangements for the HIGH-Q programme, an update on the status of workforce enhancement and the short-term employment of intervention staff, an assessment of the contribution of the additional workforce to the quality of newborn care at the NBUs and finally to explore opportunities to retain and absorb the project nurses. These efforts culminated in a brief face-to-face meeting with three of the four CECMs at a CECM forum. Our interest to have continuity of nursing workforce conflicted with the position of CECMs. The feedback from the CECMs cited county HR practices which promote a competitive recruitment process, leaving no room for the direct absorption of staff from the Programme into the county public service. Options for inviting the HIGH-Q Programme nurses to be part of recruitment once public funding for staffing at the county was secured were discussed, offering some promise that staff would be afforded opportunities through open recruitment. This discussion, however, took place at a time of a major problem nationwide in recruiting new health staff linked to national budget caps with direct implications for the County governments. The Public Finance Management (National Government) Regulations, 2015 (Kenya)²⁶ imposes a limit of 35 per cent expenditure on county staff salaries and benefits against total county revenues. According to the latest report available, on average, the County governments have exceeded this limit²⁷.