Background
Aim and objective
Methods
Study context
Study design
Sampling strategy and recruitment
Respondent | Kenya | Malawi | Nigeria | Tanzania | ||||
---|---|---|---|---|---|---|---|---|
Number of facilities sampled | 4 | 5 | 7 | 5 | ||||
Interview type | IDIs | FGDs | IDIs | FGDs | IDIs | FGDs | IDIs | FGDs |
National policymakers | 5 | - | 2 | - | 4 | - | 2 | - |
International stakeholders working in SSNC (e.g., WHO, UNICEF, USAID, Save the Children) | 1 | - | 6 | - | 5 | - | 2 | - |
NEST360 team (includes M&E manager, data officers, biomedical engineers) | 4 | - | - | 1 (n=5) | 2 | 1 (n=4) | 5 | - |
Funders - national | 1 | - | 2 | - | - | - | 3 | - |
Device distributors | 1 | - | 1 | - | 2 | - | 1 | - |
Mid-level management | - | - | - | 1 (n=5) | 3 | - | 3 | - |
Hospital administrator | 4 | - | 5 | - | - | - | 2 | - |
Facility Staff working in SSNC: | Mixed cadres 2(n=12) | |||||||
Biomedical engineer | 5 | 1(n=6) | 5 | 1(n=5) | 2 | - | 4 | 1 (n=8) |
Clinician (Drs/Nurses) | 13 | 1(n=6) | 10 | 2(n=6) | 2 | 2(n=5-7) | 7 | 1(n=14) |
HMIS officers | 3 | - | 5 | 1(n=5) | - | - | 3 | - |
Medical officer in charge | 3 | - | - | - | - | - | 4 | - |
Sub-total | 40 | 2 | 36 | 6 | 20 | 5 | 36 | 2 |
Total IDIs N = 132 Total FGDs N=15 |
Data collection
Data analysis
Ethics
Results
Levels of Socio-ecological framework | Thematic area | Key mitigation strategies employed | Key gaps to address |
---|---|---|---|
POLICY (national policymakers) | Rapid policy development | • Rapid guidelines development and implementation • Responsive feedback mechanisms and flexibility • Continual updating of policies/guidelines • Training on new policies conducted | • Top-down policy development process lack insight of healthcare workers and communities • Lack of specific guidance for neonates • Minimal funds to support training (Tanzania) |
New collaborations and investment | • Pooled funding streams and new domestic funders • Government funds available for PPE • Local philanthropic funding calls/ community based assistance • Multi-sector collaborations (Education, health, WASH) | • Lack of specific funding allocations for SSNC • Limited cross departmental collaboration • Need to strengthen community engagement and participation | |
HEALTH SYSTEM IMPLEMENTATION(mid-level managers)* | Information systems | • Enhanced demand for data • Electronic data shifts speeded up • Increased ownership and accountability of data at facility level | • Culture of data use missing • Lack of ownership of data at facility level • Insufficient equipment to support shift to electronic data (e.g. hardware) • Data not used in funding proposals |
Devices | • Hastened roll out of O2 due to pandemic • New equipment/devices and oxygen systems • Shared O2 allocation decisions within and between hospitals • Good supply of PPE and handwashing devices/systems • Use of telemedicine for training of equipment • Pre-emptive planning for supplies (O2 etc) • Emphasis on planned preventive maintenance | • Lack of toolbox for equipment • Lack of locally available spare parts • Slow procurement process • Equipment shortages • Lack of training/ proper manuals • Minimal coordination between biomeds and clinicians • Lack of airtime for biomeds to support telemedicine | |
FACILITY AND WARD SERVICE DELIVERY(facility implementers)* | Service delivery | • Stronger IPC focus • New ward layouts (inborn/outborn, by dependency, by COVID status) • New newborn wards created • Visitation times and numbers limited • Shift to telemedicine for follow up • Changes in opening hours | • Limited space in wards • Early discharge to community • Staff rotations |
Human resources for health (HRH) | • Training on COVID-19 and IPC • Innovative training & troubleshooting (e.g., online, Whatsapp) • Financial support during COVID-19 • Use of locum staff/ students • Supervision/mentoring • Counselling services • Transport and insurance provided (Kenya) | • HRH shortages • Poor mentorship • HRH wellbeing support lacking • No clinician supervision structures • Few specialists • Need to train more biomeds • Shifts by experience (biomeds) • No vaccination offered to health staff (Malawi) | |
COMMUNITY LEVEL | Community engagement | • Downward referrals for non-complicated deliveries • Proactive messaging to communities • Working with CHWs, community leaders to support messaging for SSNC and IPC | • Need to strengthen referral systems • Need to strengthen primary healthcare units – including equipment |
Pathway 1: COVID-19 specific responses with secondary benefits to SSNC
Rapid policy development and adaptation
‘I would say we responded promptly and we responded efficiently… we watched the trend that the pandemic was taking and the protocols given from WHO, cascaded down to National Centre for Disease Control, and given to us by the Lagos State government which we promptly instituted in our own facility... So, we senior facility staff had to ensure that everyone complied with the protocols, we also educated everyone to make sure that as senior personnel, the necessary information that the junior personnel needed are available...’ (FGD - Paediatrician, Woman, Nigeria)
‘...Even for older children (policy) was not that detailed, you find it probably just a paragraph, if you can see those green booklets over there (pointing) those were the national guidelines for COVID but the section for paediatric is not that extensive and just covers paediatric in general not neonatal’. (IDI, Hospital Director, Tanzania)‘R: management at this hospital will sat down and formulated some of the guidelines, but I think, you know, this is a new thing so most of the things were over looked and maybe we EVEN didn’t consider the neonate itself…I: Alright, so actually realising that some of the issues were missed out, did you do anything to address to that?R: Yeah!… We are improvising, for example in isolation ward we identified a certain room where we took like a heater put in that, a phototherapy machine put in that, but also a CPAP… as an improvised room there is a window there, but you know in nursery we are not supposed to have windows.’ (IDI, Neonatal Nursing Officer, Woman, Malawi)
New and collaborative funding partnerships
‘The paying of staff compensation, need for cars and fuel to facilitate dissemination of the guidelines to reach the districts you must have financial resources, therefore financial aspect was a dilemma.’ (IDI, Hospital Director, Tanzania)
So, everyone plays a role, activities were coordinated, even the support for oxygen was also involved. However other actors were coming in to give an update on how far they have gone with oxygen support, the oxygen plants, the oxygen cylinder, who is supporting what and at which hospitals, where are the gaps and who can actually cover that gap….’ (IDI, Funder, Woman, Tanzania)
Improved oxygen supply
‘A lot of opportunities [for SSNC] came up. Due to the government seeing the lapses that COVID brought, supports are now being offered to health facilities in the area of oxygen security… there are now increases in the number of oxygen cylinders in facilities.” (FDG, biomedical engineer, Man, Nigeria)‘…we have used resources of COVID to strengthening the health systems which directly benefits the maternal and newborn health activities, in terms of improving WASH services, WASH infrastructure, in terms of providing of oxygen for example the provision of oxygen now we need it for COVID right? But oxygen is a determinant in the survival of newborn... There has been lack of oxygen in many locations, we have seen many newborns dying, but now many locations have oxygen concentrators, oxygen cylinders and continued supply of oxygen so the resources have been moved from here and there.’ (IDI, Funder, Man, Malawi)
‘we really wanted to have piped oxygen and when COVID came in, it fast tracked that, now we are able to have piped oxygen in the ward, which was actually a major problem before.’ (IDI, Neonatal Nurse, Woman, Kenya)
‘Initially during the very first COVID wave, the government worked on oxygen service to be available. Oxygen plants were installed in seven regional referral hospitals and the government has continued to expand the investment to other hospitals. The staff were trained to ensure the services continues… government funding was set up to keep the service consistent at all times’ (IDI, biomedical engineer, Man, Tanzania)‘we can fill almost 30 cylinders a day and be used for emergency and for sale’ (IDI, biomedical engineer, Woman, Tanzania)
Strengthened IPC practices
‘You know one of the ways of preventing COVID spread is adequate and appropriate hand hygiene, and hand hygiene has more to offer neonatal care than just wanting to prevent COVID.’ (IDI, Paediatrician, Woman, Nigeria)‘… nowadays we really try washing completely like those incubators … so we have seen the other infections going down.’ (IDI, Neonatal Nurse, Woman, Kenya)
Pathway 2: Health system mitigation strategies and adaptations during the pandemic with secondary benefits to SSNC
Enhanced information systems
‘Before this COVID-19, we used to collate data within an interval of every three days, but now, we are collating data on daily basis because we won’t like a situation where we miss out of a vital information on any patient that is why we do this on daily basis now.’ (FGD, HMIS, Woman, Nigeria)“The COVID pandemic required us to move to electronic means of data recording; however, we are incapacitated to adjust to this demand in electronic shift due to insufficient laptops for work, and this has limited our productivity at this time.” (IDI, HMIS, Man, Nigeria)
‘Also gave an awareness that we as an institution or we as a data department got training on how to analyse data and create more accurately plans unlike in the beginning where we were seeing the data just as normal information but with this they added to us power that data are of important.’ (IDI, HMIS, Man, Tanzania)
Human resource adaptations and supportive strategies
‘COVID has had enormous impact when it comes to issues such as staffing… people working in a designated facilities are pulled out of those facilities to work in these isolation centres … [this] could negatively impact the staff because they are more frequently rostered… this could lead to burnout… this negatively impacts the care of small and sick newborn…On the other side…in terms of capacity building, COVID enabled access to a lot of online training and information that could help improve individual staff knowledge and skills which could make a better person and enable them to deliver care in more appropriate way..’ (IDI, Paediatrician, Woman, Nigeria)‘Some staff had a relative… had a COVID (case) in the household so it created a gap. So what we did we beefed up staff but those new recruits… so had an intensive orientation plan for the first two weeks, where we would have a unit matron a qualified in the nursery and new recruit to orient them on the protocols, the machines and everything…So I think that orientation plan helped us.’ (IDI, Neonatal Unit Matron, Woman, Malawi)
'the one thing that.. worries me for the future in terms of sustainability post COVID-19 is that COVID-19 has been associated with money, so if you work with a COVID-19 patient you should be paid, health workers all want to receive something… but these are things that we as health workers are supposed to do whether there is money or not, so that is my concern.’ (IDI, Hospital Director, Man, Malawi)
‘…they brought psychologists to have sessions with patients and staff to help in the anxiety and fear so at least the fear was allayed and the confidence was boosted, you know nurses are the most who come into contact with the patients first most of the time, so they were now able not to run away from the patients but know the mode of transmission and prevention so they were able to give services with confidence.’ (IDI, Hospital Administrator, Woman, Kenya)
Service delivery changes and innovations
Yes, it is a good thing, it is an easy thing one can do maybe with the new generation but for those of us who were bred in the old analogue ways, I always believe in it is always good to touch a patient. (IDI, Paediatrician, Woman, Kenya)
‘Well, yes, I will say we use zoom to see babies now. When the mothers call me to say ‘doctor, my baby’s breathing is sounding somehow’ I will say okay, can we do WhatsApp video call now, let me look at the baby. Sometimes, we tell the mothers that if they have complaints, take a video clip, send it to me electronically, via WhatsApp, we look at it, discuss it, and give feedback to the mother… However, poor internet service and high internet service cost have been additional challenges. I particularly feel bad for my younger doctors that have to use their money to purchase mobile data while also purchasing nose masks because I can’t buy it for them all as we don’t have provisions for such so it’s extra burden on them.’ (IDI, Paediatrician, Woman, Nigeria)
‘... So, if you are deployed in room 6, you know today I am in acute room. So, you really prepare yourself psychologically that I will really be busy but at least at the end of the day, I will evaluate myself and say, I did something for this baby.’ (IDI, Neonatal Nurse, Woman, Kenya)
Enhanced community engagement
‘Before discharge, we sit down and we advise them… to restrict the numbers of people coming to the house, we also advise them to at least have a bucket of water and soap so that before anyone comes in or touches the baby should at least wash their hands, before taking care of the baby, but what we stress most is restrict people who come in because they may not know who is sick or not, who is COVID positive or not..’ (IDI, Clinician, Man, Malawi)
‘we need education to community, because you and I are both witnesses that there was a time in Tanzania used to believe that COVID, it is not for us, but it is here, so if the community was educated and equipped with knowledge….’ (IDI, Hospital Director, Tanzania)
Enhanced maintenance of devices
‘…we take capacity measurements every day so that we advise when it is below a certain point like now we don’t go below 20% of the capacity so that we give ourselves time between 20 and 10 to come and refill’. (IDI, Biomedical engineer, Woman, Kenya)‘…because of the pandemic we have to do more of maintenance more frequently so that our equipment- number one they don’t break down and number two in case there is an issue we are able to get it faster, before it breaks down.’ (IDI, Neonatal Nurse, Woman, Kenya)
‘some of the equipment are limited, especially during the pandemic. At a point in time, we had like six or eight babies requiring ventilator support but in some of our wards we have three CPAP machines. So, we had to be withdrawing [babies] which is ethically not acceptable but we have to be weighing the benefits and the risks. So what we did was that babies who were relatively stable were withdrawn from the CPAP so that we could give access to the very sick babies.’ (IDI, Clinician, Man, Nigeria)