title: Task sharing within a managed clinical network to improve child health in Malawi.
abstract: BACKGROUND
  Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health.
  
  
  OBJECTIVE
  Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home.
  
  
  METHODS
  Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts.
  
  
  CONCLUSIONS
  If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists.
authors.affiliation: College of Medicine, Blantyre, Malawi. bernadetteohare@medcol.mw.|The University of St Andrews, Saint Andrews, UK. bernadetteohare@medcol.mw.
authors.forename: Bernadette
authors.initials: B
authors.lastname: O'Hare
authors.affiliation: Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi. ajibphiri@gmail.com.
authors.forename: Ajib
authors.initials: A
authors.lastname: Phiri
authors.affiliation: Médecins sans Frontières, Allemagne, France. hajoe123@yahoo.es.
authors.forename: Hans-Joerg
authors.initials: HJ
authors.lastname: Lang
authors.affiliation: Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi. friesenjma@hotmail.com.
authors.forename: Hanny
authors.initials: H
authors.lastname: Friesen
authors.affiliation: Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi. nkennedy@medcol.mw.
authors.forename: Neil
authors.initials: N
authors.lastname: Kennedy
authors.affiliation: Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi. kkawaza@medcol.mw.
authors.forename: Kondwani
authors.initials: K
authors.lastname: Kawaza
authors.affiliation: Department of Basic Medical Sciences, College of Medicine, Blantyre, Malawi. cjana@medcol.mw.
authors.forename: Collins E
authors.initials: CE
authors.lastname: Jana
authors.affiliation: Department of Basic Medical Sciences, College of Medicine, Blantyre, Malawi. gchirambo@medcol.mw.
authors.forename: George
authors.initials: G
authors.lastname: Chirambo
authors.affiliation: College of Medicine, Blantyre, Malawi. wakisamulwafu@gmail.com.
authors.forename: Wakisa
authors.initials: W
authors.lastname: Mulwafu
authors.affiliation: College of Medicine, Blantyre, Malawi. theikens@medcol.mw.
authors.forename: Geert T
authors.initials: GT
authors.lastname: Heikens
authors.affiliation: College of Medicine, Blantyre, Malawi. mipando@yahoo.co.uk.
authors.forename: Mwapatsa
authors.initials: M
authors.lastname: Mipando
mesh_terms: D002648:Child; D000067576:Child Health; D003695:Delivery of Health Care; D006297:Health Services Accessibility / Q000592:standards; D006761:Hospitals; D006801:Humans; D008295:Malawi; D010372:Pediatrics; D010823:Physician Assistants; D010820:Physicians; D058996:Quality Improvement; D012017:Referral and Consultation; D012424:Rural Population; D013038:Specialization; D014937:Work