Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions

Abstract

Background: Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care.

Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns.

Results: Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed.

Conclusions: Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive.

Figure 1

Inpatient care of small and sick babies, showing health system requirements by level of care. Red text signifies tracer indicator for bottleneck tool analysis. *See Vesel et al (2015) Kangaroo mother care, Enweronu-Laryea et al (2015) Basic newborn care and resuscitation, and Simen-Kapeu et al (2015) neonatal sepsis. Neonatal intensive care image source: Getty images/Save the Children. Special care for small and sick newborns image source: Ian Hurley/Save the Children. Basic care for all newborns image source: Jonathan Hyams/Save the Children.

Figure 2

Estimated coverage of neonatal care by region of the world and level of care. *By Special Care Baby Unit, this is the highest level of care available (i.e. no Neonatal Intensive Care). Data source: Adapted from Beyond Newborn Survival: The Global Burden of Disease due to Neonatal Morbidity. Estimates of neonatal morbidities and disabilities at regional and global levels for 2010: introduction, methods overview, and relevant findings from the Global Burden of Disease study. Pediatric Research; December 2013, Volume 74, (Supplement 1).

Figure 3

Definitions of tracer indicators for inpatient care of small and sick newborn bottleneck analysis tool. For more details see the complete bottleneck analysis in the additional file 2.

Figure 4

Very major or significant health system bottlenecks for inpatient care of small and sick newborns. NMR: Neonatal Mortality Rate. *Cameroon, Kenya, Malawi, Uganda, Bangladesh, Nepal, Vietnam. **Democratic Republic of Congo, Nigeria, Afghanistan, India, Pakistan. See additional file 2 for more details.

Figure 5

Individual country grading of health system bottlenecks for inpatient care of small and sick newborns. Part A: Heat map showing individual country grading of health system bottlenecks for inpatient care of small and sick newborns. Part B: Table showing total number of countries grading significant or major for calculating priority building blocks. DRC: Democratic Republic of the Congo.

Figure 6

Neonatal nursing as part of national human resource planning. ANNP: Advanced Neonatal Nurse Practitioner.

Figure 7

India's health systems approach to improving inpatient care for small and sick newborns. *Janani Suraksha Yojna (JSY): a conditional cash transfer to promote institutional delivery); **Janani Shishu Suraksha Karyakram (JSSK): reducing out of pocket expenses by making free health care an entitlement; ***Rashtriya Bal Suraksha Karyakram (RBSK): looks at developmental delays and disabilities, birth defects and deficiencies, covering age group of 0-18 years of age. Other abbreviations: AIIMS: All India Institute of Medical Science; ASHA: Accredited Social Health Activist; CPAP: Continuous Positive Airway Pressure; India Newborn Action Plan (INAP); NMR: Neonatal Mortality Rate; NBSU: Newborn Stabilisation Units; ROP: Retinopathy of Prematurity; SNCU: Special Newborn Care Unit; UNICEF: United Nations International Children's Emergency Fund; WHO: World Health Organization.

Figure 8

Key messages and action points for inpatient care of small and sick newborns.