Health Services that Deliver for Newborns Post-Doctoral Researcher Effective coverage of essential in-patient newborn services in Nairobi County David Gathara Post-Doctoral Researcher KEMRI Wellcome Trust Work developed in collaboration with the county

Background Despite the progress in reducing U-5 mortality, neonatal mortality still accounts for 45% of all child deaths deaths “estimates suggest the greatest effect [on newborn survival] would come from a focus on the care of small and ill neonates, Much of this effect is potentially achievable through newborn care services in subdistrict and district level hospitals.” In Kenya we don’t have a good understanding of what care is currently being provided for sick newborns and what the quality of that care is Nairobi County has NN mortality of 39 per 1000 live births (national average 22/1000). Nairobi has 89% hospital delivery and 14% of the health facilities nationally With mothers being increasingly encouraged to deliver in facilities, it is important that these facilities are able to deal with any complications that may arise for the newborn, even if this is just to have a good referral system in place to other facilities with high quality care. Without a clear understanding of how care is currently delivered and what the gaps are, it becomes difficult to discuss how improvements can be made.

Nairobi Newborn Study Estimating the need Identify facilities Estimate admissions Structural assessment Examine process of care Assess knowledge of nurses

METHODS Access gap Quality scores Structure Process Knowledge Estimating need Literature review Admission register review All neonatal admissions for one year Structural assessment Check list for infrastructure, staffing, equipment, drugs Medical record review 1183 records sampled: proportional sampling/weighting Correct’ defined a priori by national guidelines Nursing knowledge questionnaire 125 maternity and newborn unit nurses sampled Vignettes and direct questions Access gap Quality scores Structure Process Knowledge

Need inpatient services: 18% of live births BMJ Global Health, Murphy et al, 2017 Newborns needing care <200 200 - 300 >300 - 700 >700 The 183 sick newborns/1000 live births estimate was applied to the live births population- calculated by taking 2009 census population, adjusting for population growth in last 7 years, applying the CBR of 3.1 from the KDHS2014.

34 facilities providing 24/7 inpatient service Legend G FBO Military Private Public Newborns needing care <200 200 - 300 >300 - 700 >700

What is the need for neonatal inpatient care? Using population projections to 2015 we estimate the need for INC services during study period (mid-2014 to mid-2015) = 21,966 18% of all live births will require inpatient newborn care 12,202 admissions were registered across 31 facilities in the same period

Where is inpatient neonatal care (INC) provided? 34 facilities 1 excluded & 2 declined  31 participated (30 with maternity) Define INC; Registers for one year and structural assessment Just 5 facilities = 84% of admissions Range of settings: discrete NBU v room on maternity A: Facilities providing 24/7 inpatient newborn services (INC facilities) in Nairobi City County. B: Annual (1st July 2014 – 30th June 2015) admissions among 31 INC facilities. C: Cost of one overnight accommodation in a newborn unit (NBU) across 28 INC facilities. D: Percentage occupancy of NBUs across 29 INC facilities.

Summary structure score per facility

Summary process score per facility

Knowledge scores Here scores for sets of questions. Also explored these by level of training and whether nurses were dedicated or not.

What is the quality of care of provided?

What quality of care is being accessed?

Relationship between summary process score and structural capacity score Bubble size= patient volume Blue=public Orange=mission Yellow=private Note that the x- and y-axes do not begin at zero.

EFFECTIVE COVERAGE Low quality: process ≤0.5 or structure <80 or knowledge ≤0.6 High quality: process >0.6 and structure ≥80 and knowledge >0.8 Quality of care received by all babies estimated requiring inpatient care

Almost 1 in 5 live births requires inpatient neonatal care in NCC There is poor effective coverage of essential inpatient neonatal services with barriers to care being: Inadequate provision - about 45% on newborns have no access Quality – only 25% of newborns access high quality care Cost - only 4 public health facilities Physical barriers – maldistribution of facilities with need Improving neonatal care requires an expansion of appropriate human resources for health but also improvement on the availability of resources and quality provision To Improve access to high quality for all and especially the poor, the county should consider Upgrading some facilities to provide standard of care category neonatal care Strengthening existing hospitals to reliably provide intermediate category of care Establish a country wide referral strategy and system

Health Services that Deliver for Newborns Stakeholder engagement and dissemination Ministry of Health Nairobi City County Chief nursing officer Nursing Council of Kenya National Nurses Association of Kenya Universities and training institutions Hospital managers Neonatal nurses They are very engaged. Everyone knows that there is a problem with newborns services but there is an increasing feeling that you need to bring evidence in your argument to have resources and focus to your issue. It starts a dialogue and shows where changes could be made.

Funders: Joint Health Systems Research Initiative Wellcome Trust MRC UKAID ESRC KEMRI-Wellcome Trust team Nurses Expert Group HSD-N Advisory Group Participating hospitals Mothers and Nurses that consented to the study