Developing recommendations for neonatal inpatient care service categories: reflections from the research, policy and practice interface in Kenya

Neonatal deaths contribute a growing proportion to childhood mortality, and increasing access to inpatient newborn care has been identified as a potential driver of improvements in child health. However, previous work by this research team identified substantial gaps in the coverage and standardisation of inpatient newborn care in Nairobi City County, Kenya. To address the issue in this particular setting, we sought to draft recommendations on the categorisation of neonatal inpatient services through a process of policy review, evidence collation and examination of guidance in other countries. This work supported discussions by a panel of local experts representing a diverse set of stakeholders, who focused on formulating pragmatic, context-relevant guidance. Experts in the discussions rapidly agreed on overarching priorities guiding their decision-making, and that three categories of inpatient neonatal care (standard, intermediate and intensive care) were appropriate. Through a modified nominal group technique, they achieved consensus on allocating 36 of the 38 proposed services to these categories and made linked recommendations on minimum healthcare worker requirements (skill mix and staff numbers). This process was embedded in the local context where the need had been identified, and required only modest resources to produce recommendations on the categorisation of newborn inpatient care that the experts agreed could be relevant in other Kenyan settings. Recommendations prioritised the strengthening of existing facilities linked to a need to develop effective referral systems. In particular, expansion of access to the standard category of inpatient neonatal care was recommended. The process and the agreed categorisations could inform discussion in other low-resource settings seeking to address unmet needs for inpatient neonatal care.

Identifies newborns as one of the populations for the objective of provision of essential healthcare Kenya Health Sector Strategic andInvestment Plan 2014-2018 (22) First strategic plan of the Kenya Health Policy 2014-2030, providing the medium term focus for policy objectives, including an increase in access to the essential package of health by at least 90% Target: reduce neonatal deaths by half, with a target of 15 deaths per 1000 live births in 2017 (not reached). Service delivery focus is on the prevention of mother to child transmission of HIV, perinatal conditions, congenital anomalies and immunisation. Indicators include the percentage of: deliveries conducted by a skilled attendant, newborns with low birth weight and facility-based under-5 deaths. There are no newborn inpatient-specific indicators. Kenya Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) Investment Framework 2016 (20) Presentation of a set of prioritised interventions for investment and scale up over a five year period to rapidly improve health outcomes.
Neonatal mortality rate is a key indicator. The high impact interventions relevant for newborns proposed by the report are Kangaroo Mother Care, support for feeding preterm babies, management of jaundice, neonatal resuscitation and supportive care for neonatal sepsis. Neonatal-related immediate actions to improve service are bundled with maternal health Service Availability and Readiness Assessment Mapping 2013 (64) Health service census mapping the availability of services outlined by the Essential Package for Health, the capacity (human resource, infrastructure and health product availability) and the readiness for the provision of these The census covered maternal and child health, but focused on prevention of mother to child transmission of HIV, immunisation and services relevant to older children (such as zinc and vitamin A provision).

services.
The availability of newborn services was measured (30% of primary care facilities and 46% of county hospitals provided the service) but it was not clear what these entailed. Health Facility Readiness to Provide Emergency Obstetric and Newborn Care in Kenya 2014 (21) The government of Kenya and USAID partnered to scale up emergency obstetric and newborn care (EmONC) across 15 counties. An assessment was made in 2014 of the availability of EmONC-trained healthcare workers, equipment and medications required to provide the nine EmONC signal functions (seven basic and two comprehensive).
Only one of the nine signal functions is related to neonatal care (ability to perform basic neonatal resuscitation, in the basic EmONC list), assessed as the availability of paediatric bag mask ventilation devices. The other signal functions are concerned with maternal and antenatal care. In Nairobi County, 11% of hospitals and 14% of lower level facilities were assessed as having the full capacity (equipment and commodities) to provide the seven basic EmONC signal functions Kenya Quality Model for Health Checklist (45) Conceptual framework to guide facility selfassessment of the organisation of health services, address quality issues and standardise quality improvement initiatives based on evidence and consideration of cultural context. The components are divided into structure, processes and results, with neonatal care forming one of the processes to be assessed.
Checklist covering services that should be provided from level 2: neonatal resuscitation, basic care of the newborn (including prevention of mother to child transmission of HIV, discharge timelines and health education) and the prevention and treatment of sepsis. However, it does not cover other inpatient neonatal services.

Basic Paediatric Protocols 2016 (46)
Clinical management handbook for clinicians and health workers managing newborn and child illness. Targeted at basic hospital care rather than tertiary or university hospitals, but guidance is condition-specific rather than level-specific.
Guidance on the clinical practice of newborn resuscitation, feeding, medication and the management of sepsis, prematurity, low birth weight and jaundice (including exchange transfusion). Provides an indication of the services that should be available at hospitals providing basic inpatient newborn care. National Guidelines for Quality Obstetrics and Perinatal Care (47) Reference manual for clinicians to manage conditions associated with maternal and newborn patients with evidence-based interventions.
Covers care of the normal neonate, breastfeeding, resuscitation, birth injuries, management of high risk neonates and management of neonatal emergencies. Kenya Health Sector Referral Strategy and Implementation Guidelines 2014 (6,7) Outlines the six levels of the health system and how patients, expertise, specimens and patient information should move between them, as well as the challenges that face the referral system

No newborn specific recommendations
Human Resources for Health Norms and Standards Guidelines for the Health Sector (55) Guidance on the minimum and appropriate mix of human resources required at each level of the health system Provides numbers of healthcare staff required by cadre and by facility level for paediatrics, but there is no recommendation for newbornspecific inpatient services.