The content analysis of the qualitative data collected revealed various themes related to the implementation of the free newborn care program. Out of the eleven district hospitals and a referral hospital that provided a level II SNCU in Gandaki Province, the SNCU unit was functional in eleven district hospitals but was yet to be established in Manang Hospital; thus, the results from the eleven SNCUs are presented. Hospitals operate within their unique constraints to provide uninterrupted healthcare services, and their overall status is discussed under the themes below.
Human resource impacting service delivery
Practices in human resource management
Seven of the eleven SNCUs had exclusive nursing staff, and four SNCUs had exclusive medical officers/pediatricians available, which is less than required for optimal health care. The grants, programmatic budgets, and government scholarship bond personnel made available by federal and provincial governments have allowed hospitals to acquire, develop and utilize additional staff nurses, medical officers, and pediatricians. Most of the staff working in SNCUs are hired on a contract basis, causing frequent turnover and non-retention of experienced staff. The difficulty in workload management due to short staffing, coupled with a lack of specialized training, has enabled staff to gain essential knowledge, attitudes, and skills among themselves. Concerns regarding this self-paced, peer learning approach were raised because they feel that along with certain flexibility and benefits, the absence of effective facilitation and dedicated mentoring may lead to the perpetuation of substandard practices and behaviors.
….it takes weeks for new staff to familiarize themselves with the care required in SNCU and months before they (new staff) become confident enough to be assigned unsupervised in shifts…. as their efficiency starts to improve, the contract period ends…. and the cycle repeats…. during few weeks to months until next recruits come, it is truly difficult to assign duties in shifts…. (FGD participant 6, Nurse in charge in district hospital)
To address the issue, the Family Welfare Division (FWD) has implemented SNCU onsite coaching and mentoring programs through the Provincial Health Directorate for capacity building of staff working in SNCUs, whereupon selected clinical mentors conduct onsite visits to enhance the knowledge, skills, and attitudes of staff.
…when mentors come to our workplace, they observe our work and guide us …. Practical tips for procedures such as cannulation, resuscitation, documentation, and post-resuscitation care are helpful. It has made us very knowledgeable over the days… (FGD participant 8, SNCU nurse)
Human resource constraints impacting service delivery
Most units face low nurse-to-bed ratios, work overload, and staff with no specialized training in small and sick newborn care.
…there has been much increase in babies being admitted …if one of the babies gets sick and a procedure needs to be done, a nurse and a doctor get engaged, leaving all the other babies under the care of one or sometimes two nurses…. the timing of care and medication of other babies is hampered…. imagine the havoc when two babies are critical… almost all the work needs to be handover to next shift… (Interviewee 2, SNCU nurse)
Though relieved by the usefulness of coaching mentoring programs, constraints such as time management, individual workload of mentors, systemic issues such as a shortage of mentors, limited resources, and challenges in coordination and communication between institutions have been reported as hindrances in mentoring programs.
… I am a mentor for SNCU training, but I hardly get time to engage in instructional activities…. being in charge is a lot of work in resource-limited conditions…. Even if I were to free myself, visiting different hospitals for mentoring alone is very difficult…. there is a very small pool of mentors…. for widening the mentor pool, experienced teachers from nursing and medical colleges in the province are the best solutions… coordination and communication will be a major challenge for management though…. (FGD Participant 5, SNCU nursing in charge)
Driving the human resource wagon
Despite difficulties, health workers continue to work, considering the kind words of appreciation received from consumers as a token of their hard work paying off. Being trained to provide specialized newborn care after being recruited is ideal, nonetheless, the doctors and nurses providing newborn care without specialized training, amidst a shortage of resources, are the backbone for the successful implementation of FNCP.
The number of beds in hospitals has grown more than three times the size since, but sanctioned posts have not increased after the establishment of SNCUs… we still follow norms laid out more than 15 years ago… (FGD participant 3, Unit in charge of the district hospital)
For the smooth functioning of the coaching and mentoring program, the participants have identified experienced teachers from academic institutions as a potential pool of mentors.
Measures of quality in newborn healthcare equation
Quality in SNCU care
The government of Nepal has regularly endorsed standard newborn care protocols as a basis for delivering standardized quality care. Three out of nine interview participants were aware of the SNCU care protocol and reported abiding by it; meanwhile, others were ignorant about its existence, even though they might have been following it unknowingly.
KMC is practiced regularly in district hospitals but, surprisingly, not in referral centers, where more sick small newborns are admitted. Standards such as the availability of 24-hour running water, the presence of an elbow-operated wash basin, the availability of soap, the practice of handwashing before entering the SNCU, handwashing after touching each baby, and the practice of wearing gowns, slippers, masks, and caps in the SNCU were present in most of the facilities. While many units had necessary infection prevention measures in place, the absence was prominent in units within older buildings and buildings under construction.
Hospitals follow the HMIS to record and report the services provided, with nurses being the primary recorders of patient information in SNCU registers. Peripheral centers had maintained complete registers, while some crucial patient data was missing from the register in the referral center, which serves the highest volume of admissions.
Roadblocks in quality management
Only a few staff who had received formal SNCU or newborn-related training were informed about the protocol and followed the standard practices, while those with informal training tended to follow passed-on practices. The monitoring of the implementation of guidelines and protocols is poor.
…I don’t specifically know about the guideline (national free newborn care guideline)… I have not seen it per se …. I know that the care is free and that babies are cared for in packages…. We just practice what we see and our seniors teach us… I have not seen anyone checking if the protocols have been followed…. (Interviewee 3, SNCU nurse)
The newborn data collected in SNCU registers lack digitalized records, hindering online access. Interruptions in the power supply, high workload, poor internet services, and unreliable digital infrastructure have been pointed out as barriers to data analysis and utilization for quality improvement activities.
Navigating the data-driven practice
The timely availability of SNCU-specific data registers can prevent them from using the Integrated Management of Neonatal and Childhood Illness (IMNCI) register, which is not comprehensive in recording the inpatient details of the admitted newborns, data on lab investigations, procedures, and packages of care received. Moreover, formal mechanisms like meetings, committees for analysis and utilization of generated data, and strict implementation of quality improvement processes through those committees would improve the odds of providing quality newborn healthcare.
Systemic and logistical aspects affecting neonatal care
Adherence to infrastructural guidelines
On-site observations have shown that all SNCUs have achieved the level of infrastructure outlined by the FNCP guidelines. Even though the guidelines specify dedicated space areas, only six out of eleven hospitals (with newly constructed/renovated buildings) have separate rooms for SNCUs. Only a few SNCUs have step-down rooms (2 out of 11), designated breastfeeding areas (4 out of 11), and distances less than 15 m from the maternity unit (8 out of 11), causing fragmentation of care.
Essential equipment such as radiant warmers, phototherapy machines, weighing machines, oxygen cylinders/concentrators, and infusion pumps was available in the units. While all the SCNUs have a set of essential equipment, in the case of breakdowns, repairs are delayed, ranging from weeks to more than half a year across units.
Systemic and logistical barriers to effective neonatal care
Infrastructure limitation has been reported as a primary barrier to the successful application of practices such as KMC, which require a comfortable place for mothers and increased space for family involvement to ensure continuity of care.
On-site observation has shown that some necessary equipment, such as infusion pumps and nasal prongs, is inadequate in high-case-volume centers (PoAHS, Matrishishu, Dhaulagiri Hospital). The Provincial Health Logistics Management Centre (PHLMC) is responsible for supplying the required commodities to SNCUs in district hospitals. But the tertiary institution (PoAHS), which accounts for approximately 75% of the total provincial SNCU admissions (due to increased caseload caused by case referrals from all the district hospitals), is under the jurisdiction of the federal government. To receive supplies from PHLMC, unit managers in PoAHS report having to go through lengthy bureaucratic channels and processes, complicating the receipt of supplementary supplies to cover the increased caseload.
Biomedical technicians/engineers are not readily available, hindering the timely installation, use, and maintenance of available equipment. The participants corroborated the inadequacy of the financial contribution through the packages, especially for premature infants requiring extended stays.
Adaptive strategies to cope with logistical constraints
To overcome the inadequacy of supplies within the package made available by the hospitals, unit managers reported that they often had to resort to creative measures to ensure optimal quality of care. The items/ medicines not managed through hospital supplies are bought in by the family members, incurring out-of-pocket expenditure.
… the newborn medicines (antibiotics and such) need to be prepared, and one vial dosage is surplus for small babies, so we collect the surplus from each to make a complete dose for another baby…. the CPAP(continuous positive airway pressure) machine is not available, so we use saline bottles and tubes to create bubble CPAP machines… small newborn nasal prong when unavailable, we make small holes in larger ones and make do… (Interviewee 4, SNCU Nursing in charge)
Integration of maternal and newborn health care efforts
FNCP guideline facilitates the lodging and fooding arrangement for post-natal mothers whose babies are admitted to SNCU, highlighting the linkage between maternal and newborn health. The district hospitals are abiding by the guideline, meanwhile, the referral center faces difficulty due to overcrowding and limited bed/space availability, thus preventing full adherence to the guideline.
Missing linkage in the continuum of care
The participants reported that some specific mother-related activities such as checking for and managing an inverted nipple during the antenatal examination, counseling regarding the risk of sepsis due to early rupture of membranes, strict aseptic methods during per vaginal examinations, consideration of hygiene and sanitation while welcoming newborns (customs of seeing the face of a newborn with money bills/gifts) which are known to reduce newborn infection and malnutrition are not carried out routinely and need special awareness and communication efforts from maternal health care providers.
Strengthening maternal and newborn care linkages
The participants expressed the need to involve maternal health care providers along with the neonatal counterparts while planning health service delivery for newborn care. To ascertain the inclusion of content that supports newborn care, whilst the women are in pregnancy counseling sessions, joint planning efforts enable maternal health care providers to practice the continuum of care in the mother-baby dyad.
… whenever discussions on newborn health care are held, pediatricians and nurses working in newborn units are involved…. but the obstetricians and nurses in the maternity unit are kept out of the loop. A joint effort to improve neonatal health is necessary because the mother and the baby are a wholesome entity… (FGD participant 7, Pediatrician)
Perceived value and financial relief from FNCP despite OOP costs
Client satisfaction and trust in FNCP
In the exit interviews, clients expressed relief, gratefulness, and satisfaction with the free newborn care provided by the government through public hospitals, despite initial skepticism. 93% of the clients were satisfied with the free newborn care services received.
… initially during admission when families are informed that they won’t have to pay for the newborn services, they are surprised…some even question the quality of care being provided because of the nominal expense they bear… by the end of the stay, as they witness the care being provided to the newborn and only have to spend money on few things, they are very grateful toward us and the government for providing such good services…” (Interviewee 2, SNCU nurse)
Gaps in support services
Frequently, the postnatal mothers of the newborns stay in the hospital premises while their babies are being cared for in SNCUs. Under-availability of food and/or accommodation to postnatal mothers was the most common problem verbalized by clients, followed by difficulty in obtaining some drugs (caffeine, surfactants, phenobarbitone), which, regardless of coverage in the packages, are not available either through hospital stores or pharmacies outside of the hospitals and are very expensive even if available. The family members describe going to great lengths in acquiring those medicines. Common areas of communication by staff included the availability of type of free services, the type of services/supplies to be brought out of pocket, procedures of specific interventions, treatment plan, and prognosis of the newborns. Nonetheless, the behavior of the health personnel towards clients and the inadequacy of communication regarding the status of their child were red flags identified by the clients.
Persistence of out-of-pocket expenditures despite free care packages
With nearly half of the newborns receiving package B care, clients in the exit interview reported total OOP expenditures (including direct and indirect costs) to be NRs. 3000 (IQR 1975–6125). The average direct cost of NRs 1150 (IQR 350–2050) has been reported which sums up to 50% (IQR 15–114) above the amount reimbursed by GON through respective packages A, B, and C. OOP constitute 60% (IQR 50–75) of total newborn care costs (OOP + reimbursed from GON). Of the total newborn care cost of $7208.897 (1US$ =NR133.59, PPP not adjusted) accrued by 114 clients, $2313.047 (32%) was covered by reimbursement packages, $1593.507 (22%, IQR 5–30) was borne by clients as a direct care cost out-of-pocket, and $3302.343 (46%) was an indirect care cost OOP.
Suggestions for service improvement
Common suggestions given by the clients for improving newborn care services were to manage appropriate lodging for postnatal mothers and families, to promote cordial behavior, to provide detailed information via open communication by nurses and doctors, and to monitor hospital cleanliness.
Private health institutions and newborn healthcare
Financial relief through public SNCU services
When sick newborns are referred from peripheral birthing centers, clients recall going to medical colleges and other private institutions previously and being forced to bear extra healthcare expenses for care.
…my first baby had to be admitted to the NICU because he was born before time… last time I spent more than 1 lakh rupee in 10 days at a private hospital… this time my second baby had passed stool in the womb and had to be admitted… I only paid 12 thousand rupees, nearly 10 times less than the previous for 8 days total (a client exiting PoAHS after discharge)
Mainstreaming private institutions in free newborn care
Despite policy provisions, the extent, quality, and cost of newborn care in medical colleges and private facilities are not regulated by government bodies. The participants in the FGD agreed that, keeping into account the large volume of clients resorting to private health care, providing free newborn care through private institutions is beneficial for improving newborn health status in the province.
Strengthening health system administration
Lack of coordinated referral systems increases client burden
… the absence of coordinated referral efforts and clear referral channels has compelled consumers to incur significant expenses for newborn care, which otherwise is provided freely in government hospitals…. (FGD Participant 5, pediatrician)
A pediatrician working at a medical college shared her experience about a client referred from a peripheral health facility, due to unclear directions and communication, resorted to private health facilities for newborn care. After decentralization, the channels for functional coordination and referral are disrupted, requiring re-endorsement and strengthening. To enable the maximum utilization of free newborn care services, the need to clarify the referral mechanism has been pointed out as a must-do, as the health care system has entered federalization.
Integration of financial schemes and strengthened policy support: doors to sustainability
The participants of the FGDs commended the national health insurance program being implemented while highlighting the need to integrate it with the existing safe motherhood program and free newborn care program for continuity of care and sustainability.
…. Since they are newly born, they are not enrolled in the health insurance scheme, but if this program (FNCP) can be integrated with the insurance program, the financial provisions may be streamlined. Currently, multiple sources, such as the FNCP, Safe Motherhood Program, and private insurance, are pouring finances into improving MNHs… integrating them will increase the sustainability and effectiveness of all programs…. This task falls within their (province government) purview…. (FGD participant 1, hospital manager)
Clear referral channel endorsement with necessary policy provisions has been suggested by the participants. To reinforce the implementation of the FNCP, the Province Ministry of Health and Population is expected to address issues such as providing adequate staff, arranging training opportunities, revisiting the amount of the free care package, addressing equipment shortages, and providing financial incentives to staff. The Health Directorate is expected to coordinate training through the Provincial Health Training Center, facilitate ambulance services for transfers and referrals, and create public awareness about the availability of free newborn services, whereas local levels are expected to raise awareness about free services and arrange for safe transport of sick newborns, from and back to community.
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