NATIONAL NEWBORN CARE UPDATE JAN 18 MONTHS N R RHODA NEONATAL CARE IMPROVEMENT ADVISOR NDOH - RMCH TTM 19 TH JANUARY 2015

CONTRACT REQUIREMENTS? Newborn care (NBC) added in July 2013 with appointment of nCIA 2

Goal #1: Develop a platform for the national co-ordination of neonatal care within NDOH by means of structures and function. OBJECTIVE 1: Conceive, design and facilitate the establishment of a national neonatal forum under the Child directorship within MCWHN - ie National Neonatal Co-ordinating Committee (NNCC) and include the global and national partners and NGOs in NBC Develop a National policy framework - 5 pillars of newborn care OBJECTIVE 2: Allow for the co-ordination of the NNCC with the National perinatal Morbidity and Mortality meetings (NaPeMMCo) OBJECTIVES

Goal # 2: Improving the Quality of Care of newborn health care/services at all levels OBJECTIVE 3: Dissemination of standard treatment guidelines and protocol of care to support implementation of Good Clinical Governance practices (enabling environment) OBJECTIVE 4: Capacity building and improving skills to care for sick and small newborns OBJECTIVE 5: Undertaking quality improvement activities such as mortality audits and infection control dashboards evaluations OBJECTIVE 6: Support for equipment and supplies—standards for newborn care: CPAP etc OBJECTIVE 7: Data driven decision making: planning, implementing (key interventions) and monitoring OBJECTIVE 8: Supporting demand creation activities through health promotions and removing barriers to access—WBOTS, outreach teams, mHealth, etc. OBJECTIVES

Goal # 3: Support the monitoring and evaluation systems using the DHIS and PPIP data OBJECTIVE 9: DHIS data quality - Evaluate the current DHIS data flow from facility upwards to NDOH in order to identify the bottlenecks OBJECTIVE 10: -in progress Documenting lesson learned and best practices OBJECTIVES

TECHNICAL ASSISTANCE PACKAGE Health systems Advocacy: National - structure formation + Policy input Provincial approach – Groups ABCD District – strengthen DCST Paed + Paed Nurse + Midwives Facility based data driven action plans Clinical Capacity building –Provincial master trainings – HBB+MSSN –National roll out for coverage at facility level –Midwives – HBB and MSSN routine care 6

LESSONS LEARNT Don’t take process for granted – establishing an enabling environment is paramount –Employment of nCIA at start of programme would have made a difference –Setting up NBC structures across the continuum is critical National - 1 year Provincial - ongoing District – led by the DCST so best access –Finance for roll out of interventions 7

LEGACY - INSTITUTIONALISATION 8 POSTFORUM NATIONAL Focus on NBC and incorporating NBC in all maternal Structure at NDOH Appointment of Assistant Director post within NDOH National Neonatal Co- ordinating Committee (NNCC) – chaired by DD MCWH PROVINCIAL The need to focus on NBC and incorporating NBC in all maternal Structure at provincial DOH no dedicated NBC championMCWH provincial meetings DISTRICTAppointment of DCST dyads – Paediatrician - Paed nurse Varies per province – DMT, MCWH-Propemmco FACILITY-Functional PNMM

9 HPCSA / SANC Input to the update of the MBChB undergraduate curriculum for NBC Milani Wolmarans: (NDOH Chief operations officer) Input to the new and essential NBC data elements for DHIS Clinical NBC expertise for geographic mapping using the neonatal signal functions Introduction of NBC quality of care indicators Highlight the need for surveillance surveys eg: Congenital Syphilis Dr Carol Marshall (NDOH office of standards compliance) Inclusion of the NBC standards to the national core standards Dr Lesley Bamford (NDOH equipment Bid committee) Developing the CPAP package for district hospitals Input to the bid specifications and tender process Raised awareness of a the need for an equipment maintenance MOU with tender companies Dr Terence Carter (DDG tertiary hospitals) Creating a platform to discuss the neonatal neurosurgical agenda Highlighting the need for planning of tertiary services for the next 20 years Dr Pearl Holele A core member of the National Task team for the “State of Midwifery in South Africa” – a relook at the maternal directorate policy and structure Provided input to the “ideal neonatal structure” by submitting with permission of the Western Cape HOD Dr Engelbrecht – the neonatal levels of care, case definitions and competencies at all levels of care. All these discussions are pivotal to addressing and correcting the NBC problems within NDOH POLICY TRANSLATION

GAPS – objectives OBJECTIVE 5: Undertaking quality improvement activities such as mortality audits and infection control dashboards evaluations OBJECTIVE 6: Support for equipment and supplies—standards for newborn care: CPAP etc 65 targeted hospitals for CPAP provision - none have received to date! OBJECTIVE 7: Data driven decision making: planning, implementing (key interventions) and monitoring OBJECTIVE 8: Supporting demand creation activities through health promotions and removing barriers to access—WBOTS, outreach teams, mHealth, etc. 10

GAPS – key National : Ability to perform central planning and strategy Equipment procurement eg: CPAP May 2013 Province: Appoint the provincial paediatricians to lead Establishment of a provincial NBC teams that includes – MCWH, Paed lead, RTC and DCST NBC and plan according to HHAPI- NeSS recommendations Data verification and audit by appointed audit co-ordinators Involvement of the DCST in provincial planning sessions District: Use of 7 step implementation booklet & the SAINC toolkit Robust M&E at district level Facility Roll out of CPAP Task a NBC champion to implementation plan Community Task shifting (esp in providing education in NBC according to HHAPI- NeSS, eg: PTL and steroids, exclusive breast feeding importance and adherence, ambulatory KMC involvement in getting mothers to book early in ANC –

KEY RECOMMENDATIONS 1. ENABLING ENVIRONMENT (STRUCTURES). NBC leadership at all levels of care National – Establish a Neonatal directorate within NDOH Provincial – appoint the Provincial paediatric specialist ( only 3/9 provinces appointed) District – increase uptake of the DCST Paediatrician ( only 19/52 districts appointed) Table 1: % reduction btw 2012/13 Figure: NBC leadership across the LOC MINIMUM REQUIREMENT TO EFFECT CHANGE

KEY RECOMMENDATIONS 2. RESOURCES 2.1 Financial: Ring fence money for neonatal care (2012 recommendation) 2.2. Human: Minimum requirements=Prov Paed + 50% Paed DCST Appointment of a provincial data co-ordinator 3. CO-ORDINATED PLAN – in progress already 3.1 National neonatal implementation and monitoring plans √ 3.2 Standardised Provincial plans √ 3.3 Strategic District plans X 3.4 Facility plans √

KEY RECOMMENDATIONS 4. TRAINING – in progress 4.1 Prioritise national roll out of newborn interventions in all districts Reducing Asphyxia - increase coverage of HBB to 50% by March Reducing Premature birth – “preterm package”: Tocolytics to all mothers in Preterm labour Antenatal steroid use at PHC, CHC and DH especially CPAP implementation MSSN training in districts Reducing Infection prioritise hand washing 5. MONITORING AND EVALUATION – 5.1 Standardised template across the country aligned with ENAP NBC indicators 5.2 Led by the DCST

MONITORING AND EVALUATION Indicators 1.Quality of care indicators (PPIP) –Intrapartum care (FSB>2,5kg) –Neonatal resuscitation (FSB+ENNDR >2,5kg) –Neonatal facility care (ENNDR g) 2.Process indicators –Newborn signal functions –HBB Amount of HBB master trainer Amount of people HBB trained Amount of facilities HBB trained Amount of facilities with 1 HBB facilitators 3.Outcome indicator Early NNDR

What must be maintained in order to sustain the reduction in perinatal deaths? National : –Central planning and strategy –Maintain the 2 forums- o NNCC for co-ordination of national NBC with partners o NaPeMMCo for communication with provinces and development of national recommendations Province: –Task of the provincial paediatric lead clinician to develop NBC plan according to HHAPI-NeSS recommendations –Data verification and audit by appointed audit co-ordinators –Involvement of the DCST in provincial planning sessions –Establishment of a provincial NBC teams that includes – MCWH, Paed lead, RTC and DCST

What must be maintained in order to sustain the reduction in perinatal deaths? District TA package: strengthening 6 NBC pillars –Use the 7 step implementation neonatal booklet to renew the action plans –Use the SAINC toolkit to track progress in NBC at district level –Task a NBC overseer to do M&E and evaluate NBC practices at facility level –Oversee the CPAP roll out (DCST) Facility –Task a NBC champion to implementation plan –Allow data analysis and discussion at facility level to continue - Ensure widespread use of the newborn care guidelines Community –task shifting (esp in providing education in NBC according to HHAPI-NeSS, eg: PTL and steroids, exclusive breast feeding importance and adherence, ambulatory KMC involvement in getting mothers to book early in ANC –

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