TABLE 2.

Innovations Used to Support the Establishment of Small and Sick Newborn Care, by Health System Building Block and Country

Health System Building Block	Ethiopia	India	Malawi	Rwanda
Leadership and governance	Using the National Newborn and Child Survival technical working group and stakeholder coordination meetings to harmonize plans, avoid duplication of efforts and mobilize resources to strengthen newborn and child survival interventions.	Identify high-priority districts, high-focused districts, and aspirational districts by the Ministry of Health and Family Welfare for focused interventions based on maternal and newborn health indicators to address equity gaps.	Newborn focal person to create a platform for discussing and planning for small and sick newborn care at both the national (Ministry of Health) and district (facility and ward) levels.	High-level government leads and owns activities to ensure programmatic sustainability.
Human resources	Task-shift small and sick newborn inpatient NICU care from doctors to trained nurses.16,226	National and regional collaborative centers that provide leadership and technical guidance to ensure uniform, high-quality introduction and implementation of facility-based newborn care.	Implement the COIN curriculum in preservice training for all health providers (including clinical officers) that do not receive directed training on small and sick newborn care.	Develop new cadres and staffing models, including partnership with Rwanda Pediatric Association for a continuous mentorship model.
Information systems	Integrate perinatal and maternal death surveillance and response into the national public health emergency management system.54	The SNCU online portal, a real-time data monitoring system, records vital information on the performance of SNCUs in the country as well as the long-term outcomes of discharged neonates; these data are used for guiding policy and initiating action for improving perinatal care.	A robust information system using the NEST360 platform and facility quality improvement dashboard to summarize outcomes of clinical care, enabling stakeholders to improve the quality of service.	Use electronic data management systems like electronic medical records, RapidSMS-MCH,176,227 and RapidPro228 to improve data management system (in general) and use of SMS-based system to notify mothers and newborns with danger signs in the community who need urgent care.
Infrastructure	Establish a newborn corner in all labor and delivery wards and a NICU at hospitals for comprehensive small and sick newborn care.13,36	Situate comprehensive lactation management centers close to SNCUs to ensure access to mothers’ own milk or donor human milk for admitted infants.	Create a maternity and neonatal unit in a dedicated building that is separate from other clinical services.	Bring the neonatal unit close to the obstetrics unit to avoid transfer delay and newborn hypothermia.
Health system financing	Enhance financial risk protection to access essential health services free of charge through mechanisms such fee waiver and exemption programs.	Direct benefit transfer scheme transfers cash entitlements directly to Aadhaar-seeded bank accounts of all eligible beneficiaries, such as Accredited Social Health Activists and contractual staff to further reduce delays in payments and corruption practices.	Leverage the advocacy skills of civil society and learnings from the family planning sector, which has secured budget line items and higher levels of funding in Malawi.	Establish community-based health insurance so services are accessible to all.
Medical supplies and devices	A web-based medical equipment management information system to support efficient use and proper management.	Train existing cold chain handlers to repair and maintain equipment in the SNCU. This approach was developed in Maharashtra state and then was replicated in other states.	Standardize the specifications of equipment that facilities can purchase or receive as donations to facilitate maintenance; make sure spare parts are provided and assess 7% of device cost for servicing.	An innovative neonatal transport and the DreamWarmer are 2 examples of innovation cocreated in Rwanda.
Service delivery	Health extension workers provide community-based newborn care that includes identifying newborn danger signs, treatment, and referral linkages to health center and hospital levels.	LaQshya certification of health facilities to improve quality of care during delivery and immediate postpartum period, focusing on enhancing satisfaction of beneficiaries, positive birthing experiences, and providing respectful maternity care to all pregnant women attending public health facilities.	Village health clinics that are staffed by health surveillance assistants who are able to identify and refer small and sick newborns.	Use community health workers for early identification of pregnant women, support for antenatal care visits, postnatal and follow-up; creation of center of excellence for NICUs in provinces.
Family-centered care	Family counseling tool in local language for health extension workers/health workers to counsel caregivers through the continuum of care at community and health facility levels. This tool provides an avenue to raise awareness among families about the importance of linkage to inpatient services for small and sick newborns.	Mother-neonatal intensive care unit where the mother’s bed is placed by the infant’s warmer in the NICU to support zero separation between mother and infant and maternal involvement in taking care of her own baby under guidance of staff. The mother-neonatal intensive care unit is a collaborative effort between the neonatology and obstetrics departments in each facility.	Keep mother and baby together as much as possible when in a facility.	Establishing a policy to encourage the involvement of husbands in labor, delivery, and newborn care. A “companion of choice” is included in the current newborn protocol. Curtains for privacy are provided for each family.

Abbreviations: COIN; Care of the Infant and Newborn; NICU, neonatal intensive care unit; SMS, short message service; SNCU, special newborn care unit.