Under 5 mortality in most of sub-Saharan Africa remains >100/1000 live-births and has remained unchanged for a decade or has risen in some countries including Kenya[1
]. Improving child survival will require better delivery of health services and in some cases curative care may be at least as cost effective as preventive interventions [2
]. Appropriately therefore, the delivery of health services at the community level and through primary care units has been the subject of considerable global research and calls to action[3
]. However, district hospitals that provide referral care and the complex environments in which they operate have been largely ignored[2
]. We believe that understanding how to improve the performance of district hospitals in settings such as Kenya is also important for the following reasons.
Firstly, referral care for children is commonly required. In sub-Saharan African countries between 6% and 20% of children assessed at primary care units may require referral [7
] although often they do not get it [8
]. Secondly, it has been estimated that effective hospital care can confer a considerable child survival advantage if access is good[10
]. Thirdly, district hospital care can be highly cost effective. In Bangladesh the cost per disability adjusted life year (DALY) averted attributable to a small district hospital was estimated to be $11 [11
], while Kenyan data suggest that the cost per child life saved by hospital care may be as low as $105 [6
]. Fourthly, in many countries the district hospital has a supervisory and peer leadership role within the formal primary care network. If hospitals fail to provide appropriate leadership the whole primary care network is threatened. Finally, hospitals are an established part of many health systems. Even in African countries the hospital sector consumes a major proportion of health care budgets although the relatively poor quality services they provide may limit their effectiveness and produce a poor return for this investment [12
How hospitals provide services and maximise health benefits are subjects that are therefore highly relevant to improving health systems in low income settings. Yet the question of how to deliver essential services effectively in small hospitals has scarcely been addressed.