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Staged implementation of a two-tiered hospital-based neonatal care package in a resource-limited setting in Eastern Uganda
  1. Kathy Burgoine1,
  2. Juliet Ikiror1,
  3. Sylivia Akol1,
  4. Margaret Kakai1,
  5. Sara Talyewoya1,
  6. Alex Sande2,
  7. Tom Otim3,
  8. Francis Okello4,5,
  9. Adam Hewitt-Smith4,
  10. Peter Olupot-Olupot4,6
  1. 1Neonatal Unit, Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda
  2. 2Pharmacy Department, Mbale Regional Referral Hospital, Mbale, Uganda
  3. 3Department of Obstetrics and Gynaecology, Lira University, Lira, Uganda
  4. 4Busitema University Faculty of Health Sciences, Mbale, Uganda
  5. 5Varimetrics Group Limited, Mbale, Uganda
  6. 6Mbale Clinical Research Institute (MCRI), Mbale, Uganda
  1. Correspondence to Dr Kathy Burgoine; kathy.burgoine{at}


Neonatal mortality remains a major global challenge. Most neonatal deaths occur in low-income countries, but it is estimated that over two-thirds of these deaths could be prevented if achievable interventions are scaled up. To date, initiatives have focused on community and obstetric interventions, and there has been limited simultaneous drive to improve neonatal care in the health facilities where the sick neonates are being referred. Few data exist on the process of implementing of neonatal care packages and their impact. Evidence-based guidelines for neonatal care in health facilities in low-resource settings and direction on how to achieve these standards of neonatal care are therefore urgently needed. We used the WHO-Recommended Quality of Care Framework to build a strategy for quality improvement of neonatal care in a busy government hospital in Eastern Uganda. Twelve key interventions were designed to improve infrastructure, equipment, protocols and training to provide two levels of neonatal care. We implemented this low-cost, hospital-based neonatal care package over an 18-month period. This data-driven analysis paper illustrates how simple changes in practice, provision of basic equipment and protocols, ongoing training and dedicated neonatal staff can reduce neonatal mortality substantially even without specialist equipment. Neonatal mortality decreased from 48% to 40% (P=0.25) after level 1 care was implemented and dropped further to 21% (P<0.01) with level 2 care. In our experience, a dramatic impact on neonatal mortality can be made through modest and cost-effective interventions. We recommend that stakeholders seeking to improve neonatal care in low-resource settings adopt a similar approach.

  • neonatal care
  • low resource setting
  • Africa
  • neonatal unit

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  • Handling editor Seye Abimbola

  • Contributors KB, JI, AH-S, TO and PO-O initiated the project. All authors made substantial contribution in developing the strategy for quality improvement. KB led the implementation. KB, JI, SA, MK, ST, AS, TO and AH-S contributed to the implementation of this model. KB and FO wrote the statistical analysis plan, cleaned and analysed the data. KB drafted the manuscript. All authors have seen and approved the final manuscript.

  • Competing interests None declared.

  • Ethics approval Mbale Regional Referral Hospital research and ethics committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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