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 halfhearted 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) tr aining 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 However, work indicating outdated, poor quality of case management of serious illness 10 11 revealed a need for knowledge and skills that went beyond emergency care. We therefore adapted and extended ETAT training to include aspects of neonatal care and management of serious paediatric illness covered by the WHO's Pocketbook of Hospital Care for Children, 12 specific Kenyan, national guidelines 13 and hospital self-assessment and improvement planning exercises to produce ETAT+ (described in detail in Irimu et al14 ). Although there are reports of better emergency care being introduced i n low income African settings, 15 16 descriptions of attempts to embed such approaches in a national health system in Africa are rare. We therefore describe our experience in this area.
Guiding our efforts have been evidence 10 17 and local experience that: (1) most hospital staff did not have access t o national or international guidelines; (2) training should take place within facilities and be non-residential for trainees; (3) effective teaching, particularly of skills, requires effective instructors/facilitators, who must therefore themselves be trained and quality assured, in contrast to most cascade approaches; (4) reaching preservice trainees was vital; and (5) activities must be embedded in local institutions and conducted in partnership with government. (For details of course content, design and all materials, please visit http://www.idoc-africa.org). Before we share our experiences, however, we should explain the term ‘scaling up’. Although the term has a range of meanings, 18 a common thread is the idea of moving beyond efficacy or demonstrations of feasibility to routine uptake. In this usage there are clear overlaps with ideas around dissemination and knowledge transfer. We prefer the term scaling up as it perhaps captures better the deliberate attempts to deliver widely the new best practice guidelines and skills that are the subject of this discussion.