Neonatal unit human resources: coverage for six cadres and trends for staff-to-baby ratios in 65 neonatal units implementing with NEST360 in Kenya, Malawi, Nigeria, Tanzania

Background

Implementing small and sick newborn care (SSNC) requires skilled health workers; however, there is a shortage, adversely impacting patient outcomes and health worker well-being. There are limited data and no current WHO standards for staff-to-baby ratios in neonatal units in low- and middle-income countries (LMICs) to inform policy, planning, and investment.

Methods

In 65 neonatal units (36 in Malawi, 13 in Kenya, 7 in Tanzania, and 9 in Nigeria), a health facility assessment (HFA) for SSNC and government-led quality improvement (QI) processes were implemented. Staffing data were collated from baseline HFA (Sept 2019-March 2021) and mid-2023 HFAs, and quarterly QI processes. The unit of analysis was the neonatal unit with day and night staff-to-baby ratios calculated. Ratios were aggregated overall, by country, by hospital level, and neonatal unit occupancy rates. Staff coverage and skill-mix were also analysed for nurses, doctors, clinical officers, laboratory technicians, data clerks, biomedical technicians, and engineers.

Results

For 65 neonatal units, median time between baseline and 2023 HFAs was 31 months (Interquartile Range (IQR) 29-34 months). In 2023, only 3 (5%) neonatal units had zero neonatal ward-specific nurses compared to 8 (12%) at baseline during the day. Between baseline and 2023 HFAs, median nurse-to-baby ratios were 1:6 (IQR 1:3-1:11) during the day and 1:10 (IQR 1:6-1:17) at night, with consistency over time. At baseline, only one third of neonatal units had a doctor providing care, or on-call coverage, at all times of day and night (n=20, 31%), and half of hospitals lacked 24-hour laboratory coverage (n=25, 45%) with no change over time. There were improvements in neonatal data clerk (n=32, 49% to n=58, 89%) and biomedical technician (n=45, 69% to n=56, 86%) coverage between baseline and 2023 HFAs.

Discussion

Evaluation revealed variability by country and hospital level, and important shortfalls remain in numbers of staff providing care. Neonatal survival in hospitals requires better staff-to-baby ratios, and more skilled staff. To meet the projected shortfall in the health workforce, governments must invest in training the next generation of health workers.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Sick neonates can die in minutes and having sufficient skilled staff and specialised technologies is crucial. In low- and middle-income countries (LMICs), there is an acute shortage of health workers with the worst shortages in the poorest countries in Africa and Southern Asia.

• There is growing evidence on the impact of low clinical staffing in hospitals on patient safety, outcomes including mortality and quality of care, and health care acquired infections, although most of this literature is from high-income countries (HIC).

• There are few data to inform international standards for staff-to-baby ratios in LMICs. The World Health Organization (WHO) have not yet published standard ratios. National level standards are available for some countries; in India, South Africa, and UK, nurse-to-baby ratios by level of care vary from 1:2 babies in neonatal intensive care to 1:6 babies in special newborn care units.

WHAT THIS STUDY ADDS

• This study analyses trends in staff-to-baby ratios for nurses and doctors from a large dataset involving 65 neonatal units in four countries (Kenya, Malawi, Nigeria, Tanzania). We found that median nurse-to-baby ratios were lower than national standards available for other settings, especially at night (Day: Median 1:6, IQR 1:3-1:11; Night: Median 1:10, IQR 1:6-1:17), with secondary and tertiary hospitals having even lower nurse-to-baby ratios during the day (Secondary/tertiary: Median 1:9, IQR 1:4-1:14; Primary: Median 1:4, IQR 1:3-1:6).

• This study also examines staff coverage and skill-mix for cadres including both clinical (nurses, doctors, clinical officers) and non-clinical staff (biomedical technicians, engineers, data clerks, and laboratory technicians).

  • Clinical staff: Despite improvements over time, some neonatal units (n=3, 5%) still did not have any neonatal ward-specific nurses providing care by the 2023 HFA. In addition, many neonatal units lacked doctors providing care, or on-call coverage, 24-hours per day (n=20, 31%) at baseline, and only half of neonatal units had any paediatricians or neonatologists (n=32, 49%) providing care or supervision with no improvements over time.

  • Non-clinical staff: Half of hospitals lacked 24-hour laboratory coverage at baseline (n=25, 45%) with no improvements over time. However, there were improvements in neonatal data clerk (n=32, 49% to n=58, 89%) and biomedical technician (n=45, 69% to n=56, 86%) coverage between baseline and 2023 HFAs.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Increased investment is needed to enable staffing levels sufficient for high-quality neonatal care.

• Staff coverage and skill-mix data for all cadres is also foundational to inform health workforce allocation, training, planning, and forecasting.

• More routine data on staff-to-baby ratios are crucial for informing increased resource allocation to transform quality of care, and to inform government resource allocation and for developing national and international recommendations for standardised ratios in neonatal units.