Quantifying health facility service readiness for small and sick newborn care: comparing standards-based and WHO level-2 + scoring for 64 hospitals implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania
Authors: Penzias Rebecca E. , Bohne Christine , Gicheha Edith , Molyneux Elizabeth M. , Gathara David , Ngwala Samuel K. , Zimba Evelyn , Rashid Ekran , Odedere Opeyemi , Dosunmu Olabisi , Tillya Robert , Shabani Josephine , Cross James H. , Ochieng Christian , Webster Harriet H. , Chiume Msandeni , Dube Queen , Wainaina John , Kassim Irabi , Irimu Grace , Adudans Steve , James Femi , Tongo Olukemi , Ezeaka Veronica Chinyere , Salim Nahya , Masanja Honorati , Oden Maria , Richards-Kortum Rebecca , Hailegabriel Tedbabe , Gupta Gagan , Cousens Simon , Lawn Joy E. , Ohuma Eric O. ,   with the Health Facility Assessment Data Collection Learning Collaborative Group, 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 , A. Ojelabi Oluwaseun , Ovuoraye John Ajiwohwodoma , Mujaid Balogun Adeleke , Fetuga Adedoyin , Okanlawon Juilana , Awosika Flora , Michael Awotayo Olasupo , Abiodun Omotayo Adegboyega 
Published: March 2024

Abstract
Background
Service readiness tools are important for assessing hospital capacity to provide quality small and sick newborn care (SSNC). Lack of summary scoring approaches for SSNC service readiness means we are unable to track national targets such as the Every Newborn Action Plan targets.

Methods
A health facility assessment (HFA) tool was co-designed by Newborn Essential Solutions and Technologies (NEST360) and UNICEF with four African governments. Data were collected in 68 NEST360-implementing neonatal units in Kenya, Malawi, Nigeria, and Tanzania (September 2019-March 2021). Two summary scoring approaches were developed: a) standards-based, including items for SSNC service readiness by health system building block (HSBB), and scored on availability and functionality, and b) level-2 + , scoring items on readiness to provide WHO level-2 + clinical interventions. For each scoring approach, scores were aggregated and summarised as a percentage and equally weighted to obtain an overall score by hospital, HSBB, and clinical intervention.

Results
Of 1508 HFA items, 1043 (69%) were included in standards-based and 309 (20%) in level-2 + scoring. Sixty-eight neonatal units across four countries had median standards-based scores of 51% [IQR 48–57%] at baseline, with variation by country: 62% [IQR 59–66%] in Kenya, 49% [IQR 46–51%] in Malawi, 50% [IQR 42–58%] in Nigeria, and 55% [IQR 53–62%] in Tanzania. The lowest scoring was family-centred care [27%, IQR 18–40%] with governance highest scoring [76%, IQR 71–82%]. For level-2 + scores, the overall median score was 41% [IQR 35–51%] with variation by country: 50% [IQR 44–53%] in Kenya, 41% [IQR 35–50%] in Malawi, 33% [IQR 27–37%] in Nigeria, and 41% [IQR 32–52%] in Tanzania. Readiness to provide antibiotics by culture report was the highest-scoring intervention [58%, IQR 50–75%] and neonatal encephalopathy management was the lowest-scoring [21%, IQR 8–42%]. In both methods, overall scores were low (< 50%) for 27 neonatal units in standards-based scoring and 48 neonatal units in level-2 + scoring. No neonatal unit achieved high scores of > 75%.

Discussion
Two scoring approaches reveal gaps in SSNC readiness with no neonatal units achieving high scores (> 75%). Government-led quality improvement teams can use these summary scores to identify areas for health systems change. Future analyses could determine which items are most directly linked with quality SSNC and newborn outcomes.