title: Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions.
abstract: BACKGROUND
  Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care.
  
  
  METHODS
  The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns.
  
  
  RESULTS
  Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed.
  
  
  CONCLUSIONS
  Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive.
authors.forename: Sarah G
authors.initials: SG
authors.lastname: Moxon
authors.forename: Joy E
authors.initials: JE
authors.lastname: Lawn
authors.forename: Kim E
authors.initials: KE
authors.lastname: Dickson
authors.forename: Aline
authors.initials: A
authors.lastname: Simen-Kapeu
authors.forename: Gagan
authors.initials: G
authors.lastname: Gupta
authors.forename: Ashok
authors.initials: A
authors.lastname: Deorari
authors.forename: Nalini
authors.initials: N
authors.lastname: Singhal
authors.forename: Karen
authors.initials: K
authors.lastname: New
authors.forename: Carole
authors.initials: C
authors.lastname: Kenner
authors.forename: Vinod
authors.initials: V
authors.lastname: Bhutani
authors.forename: Rakesh
authors.initials: R
authors.lastname: Kumar
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Molyneux
authors.forename: Hannah
authors.initials: H
authors.lastname: Blencowe
mesh_terms: D000349:Africa; D000900:Anti-Bacterial Agents / Q000600:supply & distribution; D001208:Asia; D001238:Asphyxia Neonatorum / Q000628:therapy; D003256:Community Participation; D003695:Delivery of Health Care / Q000458:organization & administration*; D004864:Equipment and Supplies / Q000600:supply & distribution; D005260:Female; D063005:Health Information Systems; D061889:Healthcare Financing; D006760:Hospitalization; D006801:Humans; D007223:Infant; D007224:Infant Care / Q000191:economics* / Q000592:standards; D007226:Infant Mortality; D007231:Infant, Newborn; D007239:Infections / Q000628:therapy; D007857:Leadership; D008297:Male; D010100:Oxygen / Q000600:supply & distribution; D047928:Premature Birth / Q000628:therapy*; D058996:Quality Improvement; D000078329:Workforce
chemical_list: D000900:Anti-Bacterial Agents; D010100:Oxygen