The normalisation of under-resourcing limits the potential for improvement of critical care: evidence from a multi-method study of Kenyan hospitals.

The reduced availability of materials, staff, and health infrastructure commonly seen in Low- and Middle-Income Country (LMIC) settings is known to directly limit the ability of a hospital to provide effective care to critically ill patients. We use Health Facility Assessments (HFAs), 'hospital journeys', and in-depth interviews across five secondary and tertiary referral-level government hospitals in Kenya to explore their readiness to provide Essential Emergency and Critical Care (EECC). Our HFA reveals weaknesses in the provision of appropriate human resources but finds that respondents believe that the materials necessary to provide care for critically ill patients are generally to be found somewhere in the facilities at the time of assessment. Hence, the results of the HFA suggest sufficient resources are available for the provision of EECC. Our interviews and patient journey analyses make it clear however, that there is an absence of systems that would allow adequate materials to be present as and when patients need them. We use a novel patient journeys method to explore how these shortages at the point of care impact treatment of critically ill patients and in so doing, show that Kenyan hospitals need systems not only for managing these important commodities, but for deploying them in a way that allows their use to become sustained and normalised. It is self-evidentiary that a lack of resources leads to poor patient care, but the reverse is not necessarily true. This matters because the assumption that LMIC hospitals are able to usefully deploy resources and training drives many global health interventions but the failed emergence of effective complex systems to manage these resources in hospitals has received relatively little focus. Short-term global health projects consisting of materials and training can result in systems that resist positive change that we describe as a being in a state of 'arrested development'. Efforts to improve critical care are fundamentally limited by hospitals in this state and this must be recognised and addressed if improvements are to be sustained.