Site Visit to Kenya. April 10-14th 2011
Visits to:-
- Gertrude Children’s Hospital
- Aga Khan University Teaching Hospital
- Kenyatta National Hospital
- Attendance at Kenyan Paediatric Association meeting (and invited presentations)
Associate Professor Jo Wilmshurst (Chair APFP, HOD Paediatric Neurology)
Professor Andrew Argent (HOD, Paediatric Intensive Care Unit).
Gertrude Children’s Hospital:
This is a small well equipped private hospital. It is about 60 years old. Medical aid is available to some 10% of the population in Kenya and a further small proportion pay directly. The hospital has about 90 beds. There is a 4 bedded paediatric intensive care unit (PICU) with the capacity to ventilate and on-site experienced nurses who can also intubate and set up intravenous access. The illnesses managed vary from meningitis to post-operative patients. Rarely cerebral malaria is seen.The centre does not perform cardiac surgery at this time but there are plans to expand the capacity of the hospital. A further 50 beds are scheduled to be built which will include a 12 bedded PICU and an MRI and CT scanning department (currently not on site). The hospital already has its own laboratory facility, radiology (for X-rays) and pharmacy. Genetic screens are very limited in the whole country and samples must be sent overseas at great expense.
The hospital does not have medical students attached to it but it does have paediatric residents completing their post-graduate training time before and after taking their exit exam.
The wards are either open plan (at a lesser rate and allowing greater observation) or single bedded rooms. The mothers are encouraged to stay with the children and to assist in the care.
There is adedicated Child Development centre – this is an impressive unit including the capacity for occupational therapy, physiotherapy, speech therapy, audiology, electroencephalography and developmental assessments to be performed. As such assessments and on-going care are located in one setting. The service has a therapist for each of the above specialities which represents an excellent capacity rarely seen in our setting. A highly insightful nurse is located in the area to assist with sedation of patients and the patient throughput. The unit can make orthotic measurements and adjustments but still has challenges with the expense of such devises.
Referrals to the hospital can be direct by the parents. Children are screened by a “triage”system – usually by a clinical medical officer and then booked into the appropriate clinic. Despite the private status of the hospital is has a policy that no sick child is turned away. Children are made medically stable before the issues of cost are addressed and then according to the capacity of the family, the child is moved to a centre to continue the care.
The definition of a child in Kenya for new patient referrals is up to 15 years of age – but in reality this is not fixed and “overage” patients are still seen. Paediatric patients reaching adolescence and adulthood remain until transfer is possible.
This hospital had an adolescent unit.
Several doctors from this centre have trained through self-funded posts or with support from the APFP. All have injected valuable skills back into the country and their knowledge has not remained at this private centre – they are either lecturing or performing clinical duties in the government setting as well. Basically the returning medical centre of the doctors trained at Red Cross is not fixed but does seem to be reliably based in Kenya i.e. these doctors successfully return to their home country, stay and improve health delivery capacity.
Aga KhanUniversityHospital:
This is a large private University Teaching Hospital. We met with members of the paediatric team and their Head of Department Professor William Macharia. The hospital has some 300 beds, 30 of which are for paediatric care. In addition three Neonatal ICU beds were seen – with the capacity to ventilate infants from 500gm upwards. Paediatric intensive care patients shared space within the adult unit. The head of this unit, though an adult intensivist, has experience in paediatric needs and has international training. Therewas a dedicated emergency ward next to the paediatric ward. These facilities were set in a separate block to the remainder of the hospital – giving the feel of a separate children’s hospital set within the main hospital.
Trainees spend 3 years in paediatrics – we met with trainees at all stages. Post training they can practice as general paediatricians but many are requesting further exposure in sub-specialities not currently available in Kenya – hence the referrals to Red Cross and other centres.
Most of the consultant staff have dual functions in government and private with either honorary contracts or sessions at the government hospital. This is already happening for neurology, nephrology and respiratory medicine. The group were very keen to build their skills and to send more trainees – they were open to the idea of some shared funding options.
The capacity had access to X-ray, CT, MRI (though not with general anaesthetics support), and laboratories on-site.
KenyattaNationalHospital:
We met with the paediatric faculty consisting of a staff of 30 paediatric consultants. Professor Aggrey Wasunna (from the division of Neonatal Medicine) is the contact supervisor for trainees referred to the APFP program. The department trains some 80 paediatric registrars at any one time with about 20 in each of the 1-3 years groups and a further 20 trainees overlapping the other year groups. This is a massive hospital, managing adults and paediatrics, is has about 1500 beds. For paediatrics there are variable bed numbers. The paediatric patients are based across 4 main wards with capacity for over 50 patients in each section. Capacity is limited by nursing and doctor to patient ratios. Many of the cots had 2-3 patients per bed. Supply of medications is unreliable based on hospital stock and families are often asked to buy medications from outside pharmacies. There is one whole bay (occupying about 15 beds) set aside for oncology patients (with mainly lymphoma and leukaemia disorders), this was in addition to an additional oncologyward. There are similar supply problems of chemotherapy agents. HIV prevalence for paediatrics was estimated at 17%. The under 5 mortality was quoted at 120 per 1000 live births. The wards had isolation cubicles (mainly for tuberculosis illnesses). Access was possible via direct referral through the emergency unit. The patient is usually screened by a clinical medical officer. The adult ICU had 5 dedicated beds for paediatrics in the 21 bedded ward, the hospital has one trained paediatric intensive care specialist to supervise the care of these patients. This is an extremely busy hospital where the majority of children both in Nairobi and the surrounding area are managed. Dedicated clinics exist for various sub-specialities – these are challenged by the large numbers of patients, the limited access to trained specialists and limited to investigations and therapies.
Prof Argent and Prof Wilmshurst presented to the trainees and the paediatric consultants on requested topics in their fields (epilepsy, sedation, critical care and the APFP program).
Kenyan Paediatric Association meeting.
This is the annual national paediatric meeting, it was held over 4 days andset in Mombassa for 2011. Prof Wilmshurst and Argent attended the first 2 days. The meeting was attended by some 120 paediatricians from Kenya mainly, but also neighbouring countries such as Rwanda, DRC, Eritrea, Djibouti, Burundi, Mauritius, Sudan and Ethiopia. The first day was dedicated to a neurology symposium. Presentations on diverse topics were given on areas from neuromuscular disease to epilepsy and coma by the national Kenyan child neurologists (Dr Osman Miyanji, Dr Donald Oyasti, and Dr Pauline Samia), Prof Wilmshurst and Prof Argent. Over the rest of the meeting themed topics were covered including endocrinology, paediatric critical care, rheumatology, nutrition, oncology,and vaccinology. The group presented as a vibrant dedicated group of paediatricians and discussions with the KPA chairman (Prof Fred Were) confirmed their capacity and intent to set up their own training sub-speciality program over the next 3 years in various areas. Following the number of trainees returning to Kenya and establishing sub-speciality services there is a real capacity to complete this.
Particular Red Cross and / or APFP trainees who were met, or evidence of their impact, seen during from the visit
Pulmonology: Adil Waris and Francis Ogara both spent time at RCCH and provided feedback during the site visit. They have both promoted respiratory medicine in Kenya, lobbying for vaccines which will have significant preventative effects for common infections.
Neurology:Pauline Samia completed training as a paediatric neurologist in 2009. She returned to work at Gertrude’s children’s hospital and has recently moved to the Aga Khan Hospital. She is assisting development of their undergraduate curriculum, is building child neurology services and has undertaken a role to assist at the Kenyatta Hospital – both in clinics and teaching under the guidance of her referring supervisor Dr Donald Oyasti. She has been successfully lobbying for improved formations of anticonvulsant therapies to be available in the country. She was part of the scientific committee for the nationalKPA meeting in 2011.
Neonatology: Mariam Karanja trained for 1 year in the neonatal unit at Groote Schuur Hospital as an APFP fellow in 2008. She returned to her work at the Kenyatta National Hospital neonatal unit. She and the head sister provided a tour of the unit and it was evident the enormous input she had provided towards enhanced care of the neonates from ventilation support to kangaroo care of the incredibly busy unit. In addition her positive and caring attitude has been of major influence to all the staff linked to this unit.Moses Lango is a current trainee at GSH on the program, he is completing the full 2 years of training and will take his exit exam later in 2011. He presented research from his current placement “Growth patterns of extreme preterm neonates in a tertiary neonatal centre – A South African experience” as an oral presentation at the KPA in 2011.
Nephrology:Bashier Admani, a past fellow in Paed. Nephrology (2006-2007) organised the 4th African Paediatric Nephrology Association Congress in Nairobi, in March 2010, under the auspices of IPNA. Bashier also presented at the recent IPNA Congress (September 2010) on feedback from a fellow post-training. He highlighted what he has achieved in his goal in establishing a Paediatric Nephrology service at Agar Khan Hospital, his role as a Senior Lecturer and reported the success of his first renal transplant. He stressed the importance of support required from Host mentors and the difficulties he had to face with Government and Hospital authorities, in terms of funding. Three trainees have completed training in nephrology at Red Cross from Kenya. They have all returned to Kenya.
Gastroenterology: A number of fellows have trained from Kenya at RC in this speciality. Peter Ngwatu who trained over 2007-2008, was at the KPA meeting and provided an update of progress in this field in Kenya. He was also part of the scientific committee for the KPA.
Paediatric Intensive Care:Isaac Tsikhutsu is about to start a one year attachment at Red Cross in PICU – from the site visit and from meeting him during the KPA it is evident that Kenya will benefit from further doctors skilled in critical care.
Acknowledgements:
The APFP extends particular thanks to Dr Pauline Samia (former trainee) who coordinated much of the site visits and the infrastructure of trip.