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Table 1 Health system bottlenecks to basic newborn care and basic neonatal resuscitation in 12 countries: proposed solutions and evidence.

From: Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions

Health system Building blocks Bottleneck Category Number of countries Proposed solution themes Evidence for proposed solutions
   BNC NR   
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  
  Poor public-private partnership and private sector compliance to national standards 2 2   
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  
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  
  Weak public private partnership/ poor collaboration 4 -   
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  
  1. BNC: Basic Newborn Care; NR: Neonatal Resuscitation; IEC: Information Education and Communication