Authors: Aaron Banda, Nelia Banda, Timothy Silweya;
Mentors: Sandra Sakala and Dr. Musonda Simwinga Supported by: NHRA
Key Message
Benefits of investing in newborn care countrywide justify the cost. The Zambian government calls for amplified investment to accelerate the reduction of deaths of newborn babies dying within 28 days of life.
The Problem
In the year, 2020 live births projection as of 2010 was 760,631 (CSO, 2010). The number of newborn deaths among the livebirths increased from 24/1000 to 27/1000 live births between 2013 and 2018 (ZDHS , 2018). In Zambia, death from severe birth asphyxia tops and currently stands at 30.2%, followed by prematurity at 27.2% and then sepsis or infections at 18.2%. It is estimated that 75% of babies born too soon die within the first week of life (WHO, 2012). The increase in newborn deaths has been attributed to among other factors, inadequate infrastructure, weak referral system, inadequate number of skilled staff, non-availability of Neonatal Intensive Care Units (NICU) and Kangaroo Mother Care (KMC). Currently Zambia has NICUs in the three tertiary hospitals out of the 1502 hospitals and delivery facilities representing 2% NICU coverage. Inadequate coverage of neonatal interventions has made it difficult to manage small and sick newborns at level one and level two continuum of care (Mubita, 2017).
Policy Options
To reduce chances of newborn babies dying within 0-7 days by at least 50% requires multiple approaches. The proposed policy options to achieve this goal include: (1) continue providing level three neonatal care in tertiary hospitals; (2) implement level two neonatal intensive care in general hospitals; and (3) implement level one Neonatal Intensive Care in all facilities that provide deliveries at district and primary health care levels.
Option 1 (Status quo): Continue providing level three Neonatal Intensive Care in tertiary hospitals.
WHAT: Tertiary hospitals in Zambia are the University Teaching Hospital and Levy Mwanawasa Teaching Hospital. These provide specialized care for the smallest, most premature, and most unwell babies who require surgical intervention referred from across the country.
Option 2: Implement level one Neonatal Intensive Care in general hospitals
WHAT: Implementing Neonatal Intensive Care at general hospitals located in provincial towns will provide care for newborn born who need more high dependence and short-term intensive care, have problems, which require to be resolved rapidly or are recovering from serious illness following treatment at tertiary hospitals.
WHY: Decentralizing NICUs from tertiary hospitals to provincial hospitals increases the level of medical care and decreases deaths of babies born too soon by 47.4% (Yuryev, 2019). In Mozambique with similar context to Zambia, introduced NICUs in provincial hospitals and observed a reduction in deaths due to asphyxia by 15%, sepsis by 11% and prematurity by 10% (Maria Elena Cavicchiolo, 2016).
FEASIBILITY:
- Implementing level one neonatal care in nine provincial general hospitals is feasible for Zambia.
- This option will be less expensive as it will utilize existing health care workers and equipping delivery facilities with basic equipment.
- High feasibility possibility to reach small babies than tertiary because of reduced referral distance. This option has potential to reduce newborn deaths by 47% (Yuryev, 2019).
- High feasibility of rolling out level one NICUs to provinces estimated at $9,204,439 compared to implementing in all facilities due to high cost.
- Higher benefits through saving lives of neonates will justify the investment costs in the end.
- In addition, University Teaching Hospital has opened a post graduate diploma training in neonatal care hence health care workers from provinces will acquire the needed skills.
- Roll out to provinces can be implemented in a phased approach prioritizing provinces with highest burden and scaling after an evaluation.
Option 3: Implement level one Neonatal Intensive Care in delivery facilities at district level.
WHAT: Level one neonatal care units (NICUs) provide basic care for the newborns. It comprises four sub levels: acute care provided at district hospitals, basic primary care at Health Centre (urban, rural or zonal), stepdown care (De-hospitalized care) and ambulatory care provided at community level.
WHY: Decentralizing neonatal care from tertiary hospitals to delivery facilities at district level increases the level of medical care and decreases deaths of babies born too soon by 40% (Yuryev, 2019). This care goes beyond primary care facilities to the household though Safe Motherhood Action Groups (SMAGs), Neighborhood Health Committees (NHCs) and other volunteers.
FEASIBILITY:
- High feasibility with larger reach to small babies, reduces referral distance to tertiary hospitals
- Potential to reduce death by about 47% of newborn deaths.
- High political will for primary health care with construction and opening of over 650 Health Posts countrywide.
- Though cost is of rolling out level one NICUs to delivery facilities across the country is high estimated at $117,612,280. However, benefits will justify costs in the long-term.
Economic Evaluation Results
| Costs | Incremental Costs | Deaths | Incremental Deaths | Incremental Cost Effectiveness Ratio | |
| Status Quo | $ 0 | 1,350 | |||
| District | $ 117,612,280.40 | $ 110,612,280.40 | 743 | -608 | $ (182,024) |
| General Hospital | $ 9,204,439.34 | $ 2,204,439.34 | 58 | -1292 | $ (1,7056.00) |
The economic evaluation results indicate that the scaling up of the NICU at General hospital is the most cost-effective strategy in Zambia as it costs $1,706 to avert an additional neonatal death.
Recommendations and next steps
Scaling up interventions to manage small and sick babies is effective in reducing deaths of newborn babies. Bearing the high cost of implementing standard neonatal care to level three hospitals and delivery facilities, implementing option two policy to set up level one neonatal care units at general hospitals in provinces is the most cost effective and feasible. These will also be the provincial training hubs for districts.
Next steps
The Ministry of Health through the Child Health Unit will coordinate implementation of this policy brief by taking the following steps:
· Present the policy brief to the Child Health technical working group coordinated by the MOH Child Health Unit
· Present the policy brief to MOH senior management
· Present the policy brief to cooperating partners at forums organized by MOH or any other forums that present such opportunities
- Ensure all general hospitals include level three Neonatal intensive care units in the 2021 to 2023 MTEF action planning.
Investing in Neonatal Interventions
Outweighs the cost
Save the Life of a Baby Born Too Soon
Acknowledgements
This policy brief would not have been possible without the support of many people through the coordination of National Health Research Authority. In particular, the authors of this brief Ms. Nelia Banda, Mr. Aaron Banda Timothy Silweya for their dedication. This team further acknowledge Ms. Sandra Sakala and Dr. Musonda Simwinga who provided valuable guidance and mentorship throughout the writing process. Our gratitude also goes to Mr. Douglas Mushinge who have been our health economist throughout the project. Their steadfast support and guidance was very handy and deeply appreciated. Many thanks go to Dr. Kunda Mutesu-Kapembwa-Consultant Pediatrician & Neonatologist and National Neonatology Coordinator for her technical support, which ensured that the policy brief is in line with the national neonatal standards. Finally, the team extends gratitude to Dr. Bobo and Ms. Getrude Kampekete- at Child Health Unit for their support in the coordination of stakeholders input through technical working group meetings.
References/ Resources
CSO. (2010). Population Estimates 2010 to 2020. Lusaka: Central Staistical Office (CSO).
DEvery preemier. (2019). PROFILE OF PRETERM AND LOW BIRTH WEIGHT PREVENTION AND CARE.
Gertrude M Kampekete, C. N. (2018). Acceptance of kangaroo mother care by mothers of premature babies. Research Gate.
Maria Elena Cavicchiolo, P. L. (2016). Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention . Cavicchiolo BMC Pregnancy and Childbirth, 16:366.
Mubita, C. (2017). Neonatal care challenges in Zambia and ways of overcoming them . International Journal of Current Medical and Pharmaceutical Research Available Online at http://www.journalcmpr.com.
WHO. (2012). Born Too Soon: The Global Action on Preterm Birth. Geneva: https://www.who.int/pmnch/media/news/2012/201204_borntoosoon-execsum-eng.pdf.
Yuryev, M. K. (2019). Some assessment results of the medical care for newborns. AVFT Archivos Venezolanos de Farmacología y Terapéutica Volume 38, number 3.
ZDHS . (2018). Zambia Demographical and Health Survey. Lusaka: Central Statistical Office.