Facility-based care of small and sick newborns: experiences with establishing a neonatal special care unit in Somaliland

Abstract

Background The goal of the United Nations is a global neonatal mortality rate (NMR) lower than 12/1000 by 2030. In stark contrast, facility-based care of small and sick newborns is limited and substandard in many low-income countries (LIC). There is a need to identify broad packages of high-quality and low-cost, sustainable interventions suitable for scale-up in fragile states and high burden countries. This article describes the process, output, and experience of establishing a neonatal special care unit (NSCU) at a governmental hospital in Somaliland. Methods We collected data from administrative documents, staff experiences, patient registries, and primary caretaker interviews covering 164 admissions through 5 months and systematized the findings within the 6 building blocks of the health care system (WHO). Results Running an NSCU in a Somali context is both possible and feasible when implementers are willing to bridge gaps on all health systems building blocks simultaneously. A verified NSCU survival rate of 85% within the first year was achieved - in line with reputable neonatal wards in the wider Eastern Africa. General caretaker satisfaction was rated as “good.” Major challenges were lack of a national regulatory framework, including an effective funding allocation; staff unfamiliarity with detailed guidelines, protocols, and job descriptions; and poor availability of medicines and other neonatal disposables. For less than US$175 in running cost per patient, including staff salaries and major equipment replacements, 75% of small and sick newborns received admission-to-discharge curative care. Public demand for facility-based newborn care was quickly growing during the implementation phase. Neonatal nurses quickly drift to nongovernmental and urban employers without a persistent and deliberate overcapacity in training courses and a strong public retention policy. A 100% service coverage in Somaliland will require dedicated wards (NSCU) with equipment at all hospitals with a labor ward, and training and deployment of about 400 neonatal nurses. Conclusions The described package of interventions may have the potential for further scale-up to district hospitals in Somaliland. Policymakers and hospital administrators should strive for a stronger national regulatory, administrative, and technical framework in neonatal curative care, facilitating the simultaneous development of all of WHO’s 6 health systems building blocks. We expect many of the findings to be transferable to the wider Somalia and other fragile LIC.