Every Newborn: health-systems bottlenecks and strategies to accelerate scale-up in countries

Summary

Universal coverage of essential interventions would reduce neonatal deaths by an estimated 71%, benefit women and children after the first month, and reduce stillbirths. However, the packages with the greatest effect (care around birth, care of small and ill newborn babies), have low and inequitable coverage and are the most sensitive markers of health system function. In eight of the 13 countries with the most neonatal deaths (55% worldwide), we undertook a systematic assessment of bottlenecks to essential maternal and newborn health care, involving more than 600 experts. Of 2465 bottlenecks identified, common constraints were found in all high-burden countries, notably regarding the health workforce, financing, and service delivery. However, bottlenecks for specific interventions might differ across similar health systems. For example, the implementation of kangaroo mother care was noted as challenging in the four Asian country workshops, but was regarded as a feasible aspect of preterm care by respondents in the four African countries. If all high-burden countries achieved the neonatal mortality rates of their region's fastest progressing countries, then the mortality goal of ten or fewer per 1000 livebirths by 2035 recommended in this Series and the Every Newborn Action Plan would be exceeded. We therefore examined fast progressing countries to identify strategies to reduce neonatal mortality. We identified several key factors: (1) workforce planning to increase numbers and upgrade specific skills for care at birth and of small and ill newborn babies, task sharing, incentives for rural health workers; (2) financial protection measures, such as expansion of health insurance, conditional cash transfers, and performance-based financing; and (3) dynamic leadership including innovation and community empowerment. Adapting from the 2005 Lancet Series on neonatal survival and drawing on this Every Newborn Series, we propose a country-led, data-driven process to sharpen national health plans, seize opportunities to address the quality gap for care at birth and care of small and ill newborn babies, and systematically scale up care to reach every mother and newborn baby, particularly the poorest.

Introduction

Reduction of the neonatal mortality rate (NMR; deaths within the first 28 days of life), has lagged substantially behind progress in child mortality, with almost 3 million deaths in 2012 being a major unfinished agenda at the end of the Millennium Development Goal era.1, 2 Globally, the average annual rate of reduction in neonatal mortality is around half that for children after the first month of life and half that for maternal deaths,³ and progress is even slower for the world's 2·6 million stillbirths.⁴ Although some countries have made substantial advances in newborn survival, progress varies between neighbouring countries and within countries. African countries have made the least progress in reducing the risk of neonatal deaths (28%) compared with countries in east Asia (65%).²

The first paper in this Series reviews changes and challenges since the first call to action for newborn survival in 2005.⁵ Although striking progress has been made in agenda setting and the generation and use of evidence in policy formulation, there is little investment, limited large-scale implementation, and major gaps in data for both coverage and process. Hence, it might not be surprising that progress in newborn survival has been slower than in the reduction of child mortality.³ However, we now have much clearer epidemiological evidence describing the size of the problem and the action priorities—where, when, and whom to focus on. The time of greatest risk for both women and babies is around birth.¹ Small babies—either preterm or small for gestational age or both—are especially vulnerable, accounting for more than 80% of neonatal deaths in south Asia and sub-Saharan Africa.¹ Targeting of small babies has been crucial to acceleration of neonatal mortality reduction in high-income and middle-income countries.⁶

Additionally, the evidence for effective and affordable interventions is clearer than ever:⁵ universal coverage of maternal and newborn care would avert 54% of maternal deaths, 71% of newborn deaths, and 33% of stillbirths⁷ as well as provide ongoing benefits throughout the lifecycle.¹ Table 1 shows the most effective intervention packages to save mothers' lives and address the three main causes of newborn mortality including basic care for neonates at birth. Full scale-up of these intervention packages could substantially reduce deaths due to prematurity (58%), intrapartum-related deaths (79%), and deaths related to infections (84%).⁷

Wide and equitable coverage of care is needed to realise a new vision of grand convergence for the richest and poorest countries of the world,9, 10 including achieving the Every Newborn goals for newborn babies and stillbirths.¹ Of the indicators tracked as a follow-on for the Commission for Information and Accountability,¹¹ only immunisation is higher than 60% coverage.¹² In fact, coverage is the lowest—and the equity gap the highest—for care around the time of birth, when mortality risk is highest. More than three-quarters of newborn deaths occur in high-mortality settings (NMR higher than 15 deaths per 1000 livebirths) characterised by struggling health systems with low numbers of health workers and facility births (table 2).¹ The interventions that have the greatest effect are especially dependent on health-system infrastructure, capacity, and resources; strengthening of clinical care in facilities is essential because it provides the backbone of services that save the lives of women and children, particularly newborn babies.7, 16

Key messages

Status for scaling up

The interventions with the most effect are mainly clinical and usually facility-based, but have the widest equity gap and the greatest health system challenges. Care around birth and the care of small and ill newborn babies have the greatest gaps in coverage, equity, and quality of care in health facilities in low-income and middle-income countries.

Health-systems bottlenecks impeding scale-up

• Interventions with the greatest bottlenecks are the prevention and management of preterm births, inpatient supportive care of ill and small newborn babies, the management of severe infections, and kangaroo mother care.

• Common constraints to scale-up of high-effect intervention packages are found in all high-burden countries and include, most importantly, bottlenecks related to the health workforce, finance, and service delivery.

• Context-specific constraints, where, despite similar health systems, an intervention such as kangaroo mother care can be scaled up in some settings or countries but faces substantial challenges to scale-up in others, despite similar health-systems bottlenecks.

Learning from fast progressing countries

Some low-income and middle-income countries have made remarkable progress in reducing neonatal deaths, and if their regional neighbours achieved the same rates, then the Every Newborn Series and action plan mortality goals would be exceeded. Lessons from fast progressing countries draw attention to specific strategies that can be implemented to overcome bottlenecks and improve access to and quality of care, such as addressing health workforce shortages, removal of financial barriers, and improvement of access to care through innovative delivery strategies such as task shifting.

Systematic scale-up in countries by overcoming bottlenecks

Adapting from Lancet 2005 Series on neonatal survival and on the basis of the analyses in the Every Newborn Series, we propose four steps for countries to phase in strategies to increase financing, improve the availability and skills of providers, and close the quality gap. Context-specific strategies are needed; countries with low mortality need to focus on quality and equity, whereas those with higher mortality need to improve supply and demand as well as equity and quality.

In 2005, Knippenberg and colleagues¹⁷ noted that the strengths and weaknesses of a health system are crucial but are often not assessed in health programme design,¹⁸ and proposed a four-step systematic approach to assess the context and scale-up of newborn care in communities and facilities. Clinical and community services are inextricably linked, and health-systems strengthening involves addressing of both.17, 19 Neonatal deaths and stillbirths could be the most sensitive marker of linkages between community and facility care. The big challenge remains how to put health-systems strengthening into practice to achieve high, equitable, and effective coverage of care. We suggest that faster progress needs systematic, context-specific identification of the health systems barriers or bottlenecks, to plan and implement strategies to accelerate progress.17, 20