Table 1 Health system bottlenecks to basic newborn care and basic neonatal resuscitation in 12 countries: proposed solutions and evidence.
Health system Building blocks | Bottleneck Category | Number of countries | Proposed solution themes | Evidence for proposed solutions | |
|---|---|---|---|---|---|
| Â | Â | BNC | NR | Â | Â |
Leadership and Governance | Policy: lacking; not updated; poorly disseminated or implemented | 6 | 5 | • Update policy and disseminate to district level | Implementation of policies that improve maternal outcomes may improve neonatal outcomes [44] |
|  | Guidelines: unavailable; not updated; poorly disseminated or implemented | 8 | 9 | • Integrate facility and community care, improve public-private partnership and implement monitoring mechanisms at all levels/sectors | Improved private-public partnership increases access to institutional perinatal services [43, 69] |
|  | Weak enforcement of policy/guidelines on breastfeeding and breast milk substitutes | 5 | - | • Develop, regularly update and disseminate guidelines and standards |  |
|  | Most births occurring at home/attended by unskilled workforce | - | 2 | • Advocacy to leaders of health facilities on newborn health services |  |
| Â | Poor public-private partnership and private sector compliance to national standards | 2 | 2 | Â | Â |
Health financing | Inadequate funding and budget allocation; inadequate financial guidelines at district level | 9 | 12 | • Advocacy to increase budgetary allocation and scope of health insurance coverage | Improving insurance coverage increases utilisation of facility maternity services, evidence on quality of care and health outcomes is inconclusive [78] |
|  | High out-of pocket expenditures for maternal and newborn services | 7 | 3 | • Equity in budgetary allocation • Disseminate financial guidelines to districts | Removal of user fees (out-of-pocket) does not significantly impact utilisation of services and may not be sustainable [41, 79] |
|  | Funding not specific/prioritised for resuscitation | - | 3 | • Widen scope of health insurance coverage for newborn services and reduce user fees |  |
|  | Low insurance coverage for newborn services | 1 | 1 | • Targeted funding for resuscitation equipment and re-training of providers |  |
Health Workforce | Inadequate knowledge and competency | 11 | 9 | • Update and harmonise curricula for training institutions; accreditation of training programs (pre- and in- service) | Competency-based training improves community health workers' effectiveness, positively impact community care-seeking behaviour and neonatal outcomes [80, 81] |
|  | Inadequate numbers and poor distribution | 9 | 8 | • Competency-based approach for training and learning. Refresher courses for resuscitation | In-service training improves knowledge and performance of facility-based workers but variable effect on health outcomes [45, 46, 82] |
|  | Poor quality of pre-service and in-service training/ refresher courses | 8 | 8 | • National workforce mapping; use data for training and mentoring programs |  |
|  | Poor supervision and mentorship | 5 | 6 | • Monitoring and supervisory system in line with job description and standards of practice |  |
|  | Lack of job description and job aids | 4 | 4 | • Equity in distribution; reduce reassignment of staff trained in newborn care |  |
Essential Medical Products and Technologies | Lack of/inadequate supplies and equipment e.g. essential medicines, warmers, bag and mask equipment | 5 | 9 | • Implement policy on essential drugs and commodities especially chlorhexidine | Provision of quality equipment and supplies at point of use improves quality of care [83] |
|  | Inadequate procurement/logistics supply system | 4 | 10 | • Logistic and supply management system to improve commodities availability at district level |  |
|  | Poor standards/quality of supplied equipment | 3 | 5 | • Locally manufacture chlorhexidine, use public-private partnership |  |
|  | Chlorhexidine not in national drug lists or implemented at district level | 8 | - | • Adequate needs assessment and due process for procurement including bidding mechanisms |  |
Health Service Delivery | Service unavailable; poor coverage/ geographic access | 7 | 6 | • Develop and implement referral and transportation mechanisms for newborns | Well-integrated health system improves health outcomes [84] |
|  | Ineffective referral mechanisms; poor linkages between community and health facility/ follow-up services | 9 | 7 | • Multi-sectorial collaboration to improve access, sanitation and infrastructure | Supportive supervision and quality perinatal audit and reviews improve adherence to standards and effectiveness of care [47, 48] |
|  | Poor quality of care (adherence to standards for hygiene and resuscitation, monitoring mechanisms, health worker attitudes) | 7 | 5 | • Continuous quality improvement at district level including supportive supervision and perinatal audit | Accreditation of facilities providing delivery services improves outcome for newborns [65, 66] |
|  | Inadequate postnatal care and follow-up / outreach services | 8 | - | • Accreditation of facilities using a standard process |  |
| Â | Weak public private partnership/ poor collaboration | 4 | - | Â | Â |
Health Management Information System (HMIS) | Newborn indicators not captured in national HMIS and reports | 9 | 8 | • Update HMIS and integrate clearly defined newborn indicators through consultative national meetings | Standardised indicators improve assessment, decision-making and quality of care [85] |
|  | Inadequate or complicated tools for information system and reporting; limited or poor quality of data | 5 | 4 | • Develop monitoring tools, set up surveillance system for important indicators | Effective perinatal audit programs improves health professionals' practices and neonatal outcomes [47, 74] |
|  | Poor documentation of clinical practice and implementation of perinatal/clinical audits and reviews | 6 | 9 | • Train and retrain HMIS personnel; disseminate protocols on perinatal audit to district level • Use local data at district meetings, for quality improvement and decision-making |  |
Community Ownership and Partnership | Poor community and male involvement to facilitate care seeking | 6 | 6 | • Multiple channels of information dissemination on importance of BNC and resuscitation | Adequate engagement and information to communities reduces major barriers to access and utilisation of facility-based services and improves health outcomes [86] |
|  | Limited community awareness and inadequate strategies to facilitate knowledge about newborn issues | 6 | 6 | • Advocacy and engagement of community leaders to sensitise the community | Community mobilisation and training of community health workers including traditional birth attendants reduces perinatal mortality, improves referrals and early initiation of breast feeding [14] |
|  | Socio-cultural and gender barriers / challenges faced by mothers | 9 | 4 | • Community representation at facility audit meetings |  |
|  | Access constraints (distance, cost of travel and care) | 7 | 4 | • Improve community and facility workforce linkages, provide context-appropriate IEC tools |  |
|  | Limited knowledge and communication skills of health providers and lack of IEC materials in appropriate local languages | 2 | 5 | • Train and retrain community workforce especially on communication skills |  |