Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF
Authors: Penzias Rebecca E. , Bohne Christine , Ngwala Samuel K. , Zimba Evelyn , Lufesi Norman , Rashid Ekran , Gicheha Edith , Odedere Opeyemi , Dosunmu Olabisi , Tillya Robert , Shabani Josephine , Cross James H. , Liaghati-Mobarhan Sara , Chiume Msandeni , Banda George , Chalira Alfred , Wainaina John , Gathara David , Irimu Grace , Adudans Steve , James Femi , Tongo Olukemi , Ezeaka Veronica Chinyere , Msemo Georgina , Salim Nahya , Day Louise T. , Powell-Jackson Timothy , Chandna Jaya , Majamanda Maureen , Molyneux Elizabeth M. , Oden Maria , Richards-Kortum Rebecca , Ohuma Eric O. , Paton Chris , Hailegabriel Tedbabe , Gupta Gagan , Lawn Joy E. ,   with the Health Facility Assessment Technical Content Reviewers, Co-design Group, Health Facility Assessment Data Collection Learning Group, Asibon Aba , Heenan Megan , Mambule Ivan , Palamountain Kara , Mkony Martha , Kawaza Kondwani , Werdenberg Jenny , Tumukunde Victor , Prullage Sue , Otiangala Dickson , Asma Betsy , Tann Cally , Kumara Danica , Medvedev Melissa M. , Yosefe Simeon , English Mike , Masanja Honorati , Kaudzu Bertha , Chiotcha Angeline , Ruysen Harriet , Campbell Oona , Murphy Gina , Herrera Samantha , Rhoda Natasha , Kak Lily , Ochieng Vincent , Wachira Sam , Okunola Catherine , Ogunsola Olabanjo Okunlola , Adewole  , Shamba Donat , Manjonda Ahazi , Kassim Irabi , Gon Giorgia , Soko Grace , Mbale Emmie , Boga Mwanamvua , Osuagwu Charles , Ngugi Mary , Chimphepo Harold , Bukola Esan , Mvanga Valentino , Kagasi Linda , Mutakyamilwa Josephat , Valle Maureen , Mwangi Carolyne , Wesonga Bridget , Chepkemoi Audrey , Chabi Joseph , Sheikh Mohammed , Ngunjiri Robert , Maina Beth , Waiyego Mary , Sigilai Enock , Wasike Grace , Cheptiany Isaac , Aritho Josephine , Bariu Josephine , Kinyua Lucy , Karimurio Lydia , Matingi Martin , Were Fred , Manguyu Wanjiku , Carns Jenny , Noxon Caroline , Andrade Esalee , Boles Taylor , Hunt Brady , Santhanaraj Akshaya , Tadros Madeleine , Kumar Meghan B. , Mchoma Christina , Bilitinyu Joseph , Chalamanda Pius , Dzinkambani Mirriam , Mhango Ruth , Stevens Fanny , Mulungu Joseph , Makhumula Blessings , Banda Loveness , Banda Charles , Chumbi Brian , Banda Chifundo , Chimombo Evelyn , Nyasulu Nicodemus , Ndau Innocent , Kumwembe Pilirani , Kerubo Edna , Ambuso Nyphry , Koech Kevin , Waithaka Noel , Wakhungu Calet , Otieno Steven , Bahati Felix , Ayaga Josphine , Obure Jedida , Nderitu Nellius , Mtambo Violet , Mkude George , Miraji Mustapha , Shayo Caroline , Nambombi Camilius , Cyrilo Christopher , Aderounmu Temilade , Wale Akingbehin Wakeel , Yemisi Odeleye Victoria , Dupe Akinola Amudalat , Awolowo Samuel , Oluwaseun Ojelabi , Ovuoraye John Ajiwohwodoma , Mujaid Balogun Adeleke , Fetuga Adedoyin , Okanlawon Juilana , Awosika Flora , Michael Awotayo Olasupo , Abiodun Omotayo Adegboyega 
Published: March 2024

Abstract
Background
Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC).

Methods
Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021.

Results
Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2–34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania.

Conclusion
This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action.