Key findings
WHAT WAS KNOWN? |
• Scale-up of WHO level-2 care for small and sick newborns, which includes the provision of continuous positive airway pressure, is receiving increasing global and national attention. This effort has potential to save 747,000 lives annually, in line with Every Newborn Action Plan's fourth target. The target aims to have at least one unit providing level-2 care in 80% of sub-national districts by 2025 • Neonatal devices are lacking or may be donated or procured from high-income settings and hence often unfit for use in low-and middle-income countries (LMIC) due to missing parts and limited training • Health managers/planners are requesting evidence-based approaches to inform equipping newborn care units with appropriate types and quantities of devices and ward furniture • We aimed to co-design, with multi-disciplinary input, a costing tool for newborn care devices and furniture for planners to use at national or subnational levels |
WHAT WAS DONE THAT IS NEW? |
A systematic process was applied: • Review of relevant costing tools, including the UNICEF Oxygen System Planning Tool being the only one that was closely related to our tool’s remit, and we adopted its stepwise approach • Co-design with multi-disciplinary experts to develop a tool for estimating required quantities and incremental costs of ward furniture and devices • Operationalise this tool to estimate set-up costs in Tanzania for 146 Districts and 25 Regional Referral hospitals |
WHAT WAS FOUND? |
• A customisable tool based on activity-based costing approach was developed allowing quantification and costing for a default 40-bed neonatal unit (or multiples thereof), including a ten-bed level-2 (high-dependency) unit for small and sick newborn care. The tool includes three components: (1) ward furniture and fixtures (18 items as default with ratios and unit costs), (2) neonatal devices (16 items as default with ratios and unit costs), (3) device installation training cost estimates for a one-day, onsite face-to-face training • Hence automatically generating cost and procurement estimates are automatically generated into a result dashboard. In Tanzania, it was feasible to collect cost data and generate reports for inclusion in the annual budgeting cycles in less than a week by a non-economic expert user |
WHAT NEXT? |
• The tool provides policymakers with evidence-based cost information to guide budget allocation and catalyse resource mobilisation for scale-up of level-2 care for small and sick newborns • Future iterations of the tool aim to include quantities and costing for consumables, spare parts, and maintenance • There is a need for more robust data on device-to-baby ratios, case mix and more data on unit costs from regions beyond Africa to improve transferability |
Background
Level of newborn care | Scope of care |
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Level 1: Essential newborn care | Services include immediate care at birth; thorough drying, skin-to-skin contact, delayed cord clamping; resuscitation when needed; early initiation and support for exclusive breastfeeding; routine care (Vitamin K, eye care, vaccinations, weighing, clinical examinations); prevention of mother-to-child transmission of HIV; assessment, management and referral of bacterial infections, jaundice and diarrhoea, feeding problems, birth defects and other problems; pre-discharge advice on mother and baby care and follow-up |
Level 2: Special inpatient newborn care | Services include: thermal care; comfort and pain management; kangaroo mother care (< 2500 g irrespective of stability); assisted feeding; safe administration of oxygen; prevention of apnoea; detection and management of neonatal infection, hypoglycaemia, jaundice, anaemia and neonatal encephalopathy; seizure management; safe administration of intravenous fluids; detection and referral management of birth defects.; |
+ Transition to intensive care | Continuous positive airway pressure; exchange transfusion; detection and management of necrotizing enterocolitis; specialized follow-up of infants at high risk (including preterm infants) |
Level 3: Intensive critical newborn care | Services include: advanced feeding support; mechanical/assisted ventilation, including intubation; screening and treatment for retinopathy of prematurity; surfactant treatment; investigation and management of birth defects; paediatric surgery; genetic services |
Aim and objectives
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Objective 1: Review relevant planning and costing tools to assess content, design and costing approaches.
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Objective 2: Co-design content for a device and furniture planning and costing tool for a functional level-2 neonatal unit.
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Objective 3: Refine and use tool to estimate cost of national scale-up in mainland Tanzania.
Methods
Methods by objectives
Objective 1: Review relevant planning and costing tools to assess content, design and costing approaches
Objective 2: Co-design content for a device and furniture planning and costing tool for a functional level-2 neonatal unit
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A default 40-bed neonatal unit, including a ten-bed level-2 unit for care of small and sick newborns, was adopted from the Tanzanian newborn unit floor plan for a District hospital. In Tanzania, this level-2 care unit is known as the high dependency unit (HDU). The floor plan includes five rooms: the HDU/ level-2 care (ten cots), a general, step-down neonatal ward (ten cots), an isolation room (five cots), a kangaroo mother care (KMC) room (ten adult beds) and a rooming-in area (five adult beds) [23] (Table 2). The default neonatal unit and level-2 care bed capacity can easily be adjusted up in multiples of ten.
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Remit to include the following components: (1) ward furniture and fixtures (permanently installed equipment or furniture in the newborn unit), (2) neonatal devices, and (3) training for use (Fig. 1). The tool was structured based on these three components and built in Microsoft Excel. Additional components were identified (i.e., (4) consumables and spare parts, and (5) maintenance) but not possible to include in this version of the tool given cost data gaps. Quantities required for the ward furniture and fixtures (first component) and user training at device installation (third component) were determined based on a default 40-bed neonatal unit. On the other hand, quantities required for the devices (second component) were based on the ten-bed level-2 care unit only (Table 2).
Quantities and cost estimates for each of the following components included in the tool? | ||||
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Room | No. of beds | Furniture & Fixtures | Devices | User Training |
High Dependency Unit (Level-2) | 10 cots | √ | √ | √ |
General Neonatal Ward (Step-Down) | 10 cots | √ | Basic only* | √ |
Isolation Room | 5 cots | √ | Basic only* | √ |
Kangaroo Mother Care Room | 10 adult beds | √ | Basic only* | √ |
Rooming-In Area | 5 adult beds | √ | Basic only* | √ |
Total | 40 beds |
Component 1: Ward furniture and fixtures (types, quantification, and costs)
Component 2: Neonatal devices (specification, quantification, and costs)
Component 3: User training at device installation
Objective 3: Refine and use tool to estimate cost for national scale-up in mainland Tanzania
Results
Objective 1: Review relevant planning and costing tools to assess content, design and costing approaches
Objective 2: Co-design content for a device and furniture planning and costing tool for a functional level-2 neonatal unit
Component 1: Ward furniture and fixtures (types, quantification, and costs)
Ward furniture & fixtures for neonatal unit | Estimated quantities for a 40-bed neonatal unita | Local suppliers’ median unit costb (US$) | Local government suppliers’ unit cost range (US$) |
---|---|---|---|
Baby cots | 25 | 194 | 187 – 219 |
Adult beds | 5 | 547 | 280 – 777 |
Special beds-KMC | 10 | 600 | 280 – 777 |
Special Chairs-KMC | 5 | 82 | 65 – 337 |
Room thermometer | 5 | 900 | 800 – 1200 |
Room heater | 5 | 64 | 61 – 67 |
Wall clock with seconds' hand | 5 | 13 | 12 – 26 |
Bedside lamp for procedures | 6 | 284 | 111 – 331 |
Emergency trolley | 6 | 816 | 757 – 1598 |
Medicine trolley | 6 | 168 | 117 – 562 |
Ordinary (instrument) trolley | 6 | 126 | 70 – 138 |
Refrigerator with freezer compartment | 3 | 421 | 229 – 2160 |
Medicine cabinets | 1 | 210 | 210 – 605 |
Water distiller 5L/Hr | 1 | 421 | 233 – 821 |
Oxygen cylinder (back up with humidifier and flow splitter) | 3 | 320 | 175 – 691 |
Oxygen cylinder (small for transport) | 3 | 244 | 65 – 338 |
Measuring tape | 6 | 2 | 1 – 4 |
Voltage stabilizer and UPS | 3 | 1150 | 582 – 2339 |
Component 2: Neonatal devices (device type and specification, quantification, and costs)
Medical devices for level-2 neonatal unit for small and sick newborn care | Estimated quantities for a 10-bed level-2 neonatal unit | Government procurement agencies’ median unit costb (US$) | Government procurement agencies' unit cost range (US$) |
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Stethoscope, neonatal* | 5 | 29 | 21 – 67 |
Ventilation bag and mask size 0 and 1* | 2 | 22 | 22 – 29 |
Infant radiant warmer* | 2 | 3444 | 3333 – 3580 |
Glucometer | 5 | 38 | 33 – 1342 |
Pulse oximeter, bedside, neonatal* | 6 | 51 | 33 – 142 |
Phototherapy unit and irradiance meter* | 2 | 1505 | 933 – 2167 |
Pump suction, electrical, portable, 220 V* | 2 | 367 | 178 – 397 |
Infusion pump* | 5 | 708 | 302 – 778 |
Syringe pump* | 2 | 808 | 778 – 1375 |
Continuous positive airway pressure* | 5 | 1333 | 1079 – 1833 |
Bilirubinometer, blood based | 1 | 1944 | 1900 – 2000 |
Oxygen concentrator* | 5 | 1000 | 933 – 1053 |
Oxygen flow splitter* | 5 | 518 | 250 – 624 |
Hemoglobinometer | 1 | 150 | 78 – 410 |
Thermometerb* | 5 | 8 | 4 – 22 |
Scale, baby, electronic, 10 kg < 5 g > b* | 5 | 89 | 83 – 164 |
Customized to add other devices as required |
Component 3: User training at device installation
Objective 3: Refine and use tool to estimate cost for national scale-up in mainland Tanzania
Medical devices for level-2 neonatal unit for partial level-3 care for small and sick newbornsa | Estimated quantities for a 20-bed level-2 neonatal unitb for partial level-3 care | Government procurement agency unit costc (US$) |
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Incubator | 2 | 7415 |
Ventilator (for neonates) | 3 | 17,556 |
Laryngoscope set, newborn & 20 tubes | 3 | 77 |
Apnea monitor | 3 | 1287 |
Exchange transfusion kit | 2 | 214 |
Retinotheraphy of prematurity screening device | 1 | 343 |
Ultrasound for cranial & cardiac scans | 1 | 7183 |
Total parenteral nutrition provision | 1 | 214 |
X-ray machine | 1 | 122,239 |
ECG unit, 3 channel, portable set | 1 | 4218 |
Blood gas analyser | 1 | 6197 |
Nebulizer machine | 1 | 64 |
Examination Screen (X-ray box) | 1 | 214 |
Neonatal transport system | 1 | 1072 |