Quantifying health facility service readiness for small and sick newborn care: comparing standards-based and WHO level-2 + scoring for 64 hospitals implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania.

BACKGROUND: Service readiness tools are important for assessing hospital capacity to provide quality small and sick newborn care (SSNC). Lack of summary scoring approaches for SSNC service readiness means we are unable to track national targets such as the Every Newborn Action Plan targets. METHODS: A health facility assessment (HFA) tool was co-designed by Newborn Essential Solutions and Technologies (NEST360) and UNICEF with four African governments. Data were collected in 68 NEST360-implementing neonatal units in Kenya, Malawi, Nigeria, and Tanzania (September 2019-March 2021). Two summary scoring approaches were developed: a) standards-based, including items for SSNC service readiness by health system building block (HSBB), and scored on availability and functionality, and b) level-2 + , scoring items on readiness to provide WHO level-2 + clinical interventions. For each scoring approach, scores were aggregated and summarised as a percentage and equally weighted to obtain an overall score by hospital, HSBB, and clinical intervention. RESULTS: Of 1508 HFA items, 1043 (69%) were included in standards-based and 309 (20%) in level-2 + scoring. Sixty-eight neonatal units across four countries had median standards-based scores of 51% [IQR 48-57%] at baseline, with variation by country: 62% [IQR 59-66%] in Kenya, 49% [IQR 46-51%] in Malawi, 50% [IQR 42-58%] in Nigeria, and 55% [IQR 53-62%] in Tanzania. The lowest scoring was family-centred care [27%, IQR 18-40%] with governance highest scoring [76%, IQR 71-82%]. For level-2 + scores, the overall median score was 41% [IQR 35-51%] with variation by country: 50% [IQR 44-53%] in Kenya, 41% [IQR 35-50%] in Malawi, 33% [IQR 27-37%] in Nigeria, and 41% [IQR 32-52%] in Tanzania. Readiness to provide antibiotics by culture report was the highest-scoring intervention [58%, IQR 50-75%] and neonatal encephalopathy management was the lowest-scoring [21%, IQR 8-42%]. In both methods, overall scores were low (< 50%) for 27 neonatal units in standards-based scoring and 48 neonatal units in level-2 + scoring. No neonatal unit achieved high scores of > 75%. DISCUSSION: Two scoring approaches reveal gaps in SSNC readiness with no neonatal units achieving high scores (> 75%). Government-led quality improvement teams can use these summary scores to identify areas for health systems change. Future analyses could determine which items are most directly linked with quality SSNC and newborn outcomes.

Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF.

BACKGROUND: Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC). METHODS: Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021. RESULTS: Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2-34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania. CONCLUSION: This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action.

Protecting small and sick newborn care in the COVID-19 pandemic: multi-stakeholder qualitative data from four African countries with NEST360.

BACKGROUND: Health system shocks are increasing. The COVID-19 pandemic resulted in global disruptions to health systems, including maternal and newborn healthcare seeking and provision. Yet evidence on mitigation strategies to protect newborn service delivery is limited. We sought to understand what mitigation strategies were employed to protect small and sick newborn care (SSNC) across 65 facilities Kenya, Malawi, Nigeria and Tanzania, implementing with the NEST360 Alliance, and if any could be maintained post-pandemic. METHODS: We used qualitative methods (in-depth interviews n=132, focus group discussions n=15) with purposively sampled neonatal health systems actors in Kenya, Malawi, Nigeria and Tanzania. Data were collected from September 2021 - August 2022. Topic guides were co-developed with key stakeholders and used to gain a detailed understanding of approaches to protect SSNC during the COVID-19 pandemic. Questions explored policy development, collaboration and investments, organisation of care, human resources, and technology and device innovations. Interviews were conducted by experienced qualitative researchers and data were collected until saturation was reached. Interviews were digitally recorded and transcribed verbatim. A common coding framework was developed, and data were coded via NVivo and analysed using a thematic framework approach. FINDINGS: We identified two pathways via which SSNC was strengthened. The first pathway, COVID-19 specific responses with secondary benefit to SSNC included: rapid policy development and adaptation, new and collaborative funding partnerships, improved oxygen systems, strengthened infection prevention and control practices. The second pathway, health system mitigation strategies during the pandemic, included: enhanced information systems, human resource adaptations, service delivery innovations, e.g., telemedicine, community engagement and more emphasis on planned preventive maintenance of devices. Chronic system weaknesses were also identified that limited the sustainability and institutionalisation of actions to protect SSNC. CONCLUSION: Innovations to protect SSNC in response to the COVID-19 pandemic should be maintained to support resilience and high-quality routine SSNC delivery. In particular, allocation of resources to sustain high quality and resilient care practices and address remaining gaps for SSNC is critical.

A feasibility study evaluating a reservoir storage system for continuous oxygen delivery for children with hypoxemia in Kenya.

BACKGROUND: Supplemental oxygen is an essential treatment for childhood pneumonia but is often unavailable in low-resource settings or unreliable due to frequent and long-lasting power outages. We present a novel medium pressure reservoir (MPR) which delivers continuous oxygen to pediatric patients through power outages. METHODS: An observational case series pilot study assessing the capacity, efficacy and user appraisal of a novel MPR device for use in low-resource pediatric wards. We designed and tested a MPR in a controlled preclinical setting, established feasibility of the device in two rural Kenyan hospitals, and sought user feedback and satisfaction using a standardized questionnaire. RESULTS: Preclinical data showed that the MPR was capable of bridging power outages and delivering a continuous flow of oxygen to a simulated patient. The MPR was then deployed for clinical testing in nine pediatric patients at Ahero and Suba Hospitals. Power was unavailable for 2% of the total time observed due to 11 power outages (median 4.6 min, IQR 3.6-13.0 min) that occurred during treatment with the MPR. Oxygen flowrates remained constant across all 11 power outages. Feedback on the MPR was uniformly positive; all respondents indicated that the MPR was easy to use and provided clinically significant help to their patients. CONCLUSION: We present a MPR oxygen delivery device that has the potential to mitigate power insecurity and improve the standard of care for hypoxemic pediatric patients in resource-limited settings.

A Comprehensive Approach to Medical Oxygen Ecosystem Building: An Implementation Case Study in Kenya, Rwanda, and Ethiopia.

Medical oxygen is an essential treatment for life-threatening hypoxemic conditions and is commonly indicated for the clinical management of most leading causes of mortality in children aged younger than 5 years, obstetric complications at delivery, and surgical procedures. In resource-constrained settings, access to medical oxygen is unreliable due to cost, distance from production centers, undermaintained infrastructure, and a fragmented supply chain. To increase availability of medical oxygen in underserved communities, Assist International, the GE Foundation, Grand Challenges Canada, the Center for Public Health and Development (Kenya), Health Builders (Rwanda), and the National Ministries of Health and Regional Health Bureaus in Kenya, Rwanda, and Ethiopia partnered to implement a social enterprise model for the production and distribution of medical oxygen to hospitals at reduced cost. This model established pressure swing adsorption (PSA) plants at large referral hospitals and equipped them to serve as localized supply hubs to meet regional demand for medical oxygen while using revenues from cylinder distribution to subsidize ongoing costs. Since 2014, 4 PSA plants have successfully been established and sustained using a social enterprise model in Siaya, Kenya; Ruhengeri, Rwanda; and Amhara Region, Ethiopia. These plants have cumulatively delivered more than 209,708 cylinders of oxygen to a network of 183 health care facilities as of October 2022. In Ethiopia, this model costs an estimated US$7.34 per patient receiving medical oxygen over a 20-year time horizon. Altogether, this business model has enabled the sustainable provision of medical oxygen to communities with populations totaling more than 33 million people, including an estimated 5 million children aged younger than 5 years.

Oxygen insecurity and mortality in resource-constrained healthcare facilities in rural Kenya.

INTRODUCTION: Pneumonia is the leading cause of death globally in children. Supplemental oxygen reduces mortality but is not available in many low-resource settings. Inadequate power supply to drive oxygen concentrators is a major contributor to this failure. The objectives of our study were to (a) assess the availability of therapeutic oxygen; (b) evaluate the reliability of the electrical supply; and (c) investigate the effects of suboptimal oxygen delivery on patient outcomes in selected healthcare facilities in rural Kenya. MATERIALS AND METHODS: A cross-sectional descriptive study on oxygen availability and descriptive case series of Kenyan children and youth hospitalized with hypoxemia. RESULTS: Two of 11 facilities had no oxygen equipment and nine facilities had at least one concentrator or cylinder. Facilities had a median of seven power interruptions per week (range: 2-147). The median duration of the power outage was 17 minutes and the longest was more than 6 days. The median proportion of time without power was out 7% (range: 1%-58%). Fifty-seven patients hospitalized with hypoxemia (median oxygen saturation 85% [interquartile range {IQR}: 82-87]) were included in our case series. Patients received supplemental oxygen for a median duration of 4.6 hours (IQR: 3.0-7.8). Eighteen patients (32%) faced an oxygen interruption of the median duration of 11 minutes (IQR: 9-20). A back-up cylinder was used in 5/18 (28%) cases. The case fatality rate was 11/57 (19%). CONCLUSION: Mortality due to hypoxemia remains unacceptably high in low-resource healthcare facilities and may be associated with oxygen insecurity, related to lack of equipment and/or reliable power.

Effective training-of-trainers model for the introduction of continuous positive airway pressure for neonatal and paediatric patients in Kenya.

Background: Continuous positive airway pressure (CPAP) is a relatively low-cost technology which can improve outcome in neonatal and paediatric patients with respiratory distress. Prior work in a lower middle-income country demonstrated degradation of CPAP skills and knowledge after the initial training. Aims: To determine if a training-of-trainers (ToT) curriculum can decrease gaps in skills and knowledge between first-generation (trained by a United States physician and nurse) and second-generation healthcare providers (trained by local trainers) in Kenya, and to describe the usage pattern, outcome and safety in patients who received CPAP following the trainings. Methods: The first day of training entailed didactic and simulation sessions. On the second day participants were taught how to train others to use CPAP. First- and second-generation healthcare providers were tested on their skills and knowledge. Unpaired t-tests were used to test for equivalence. Prospective data on CPAP usage was collected following the initial trainings. Results: 37 first-generation healthcare providers (16 nurses; 21 physicians, medical/clinical officers) were trained as trainers and 40 second-generation healthcare providers (19 nurses, 21 physicians, medical/clinical officers) trained by first-generation healthcare providers were available for skills and knowledge testing. There were no statistically significant differences between first- and second-generation healthcare providers' skills (90%, 95% CI 87-93 vs 89%, 95% CI 86-92) or knowledge scores (91%, 95% CI 88-93 vs 90%, 95% CI 88-93). A total of 1111 patients were placed on CPAP mostly by nurses (61%), prematurity/acute respiratory distress syndrome was the most common indication, nasal injury/bleeding (2%) was the most common reported adverse event, and the overall mortality rate was 24%. Conclusion: The ToT model was successful, nurses initiated CPAP most commonly, prematurity with acute respiratory distress syndrome was the most common indication, and adverse events were uncommon.