COSTING THE SCALE-UP OF SMALL AND SICK NEWBORN CARE IN ZAMBIA June 2024 A report prepared by Eliana Jiménez, Mary Nambao and Alison Morgan P a g e |1 EXECUTIVE SUMMARY Costing the scale-up of Small and Sick Newborn total cost of equipping a facility at minimum Care Units requires countries to unpack ‘what it price was less than half the cost under takes’ and ‘how much it costs’ to implement the maximum prices. system requirements of good quality of care standards. ✓ Other one-off expenses are also substantial. For example, equipment During the second half of 2022, we piloted in transport and installation costs across Zambia a Beta Version of an Excel-based costing various locations are expected to represent tool developed by GFF to cost setting-up Small between 20 to 40 percent of equipment and Sick Newborn Care Units at Level I A acquisition values. District Hospitals, across a range of typologies. ✓ Recurrent equipment costs are also We costed a base scenario (new construction, significant. In our base scenario, they range major equipment needs at base prices, mid-point from US$ 61 thousand in a small facility to costs and salaries for standard recruiting areas) US$ 92 thousand in a large unit. for three facility sizes: Small (9 beds), Medium (12 beds) & Large (18 beds). Our base scenario Human resources represent between 68% to results (USD 2022) show: 73% of recurrent costs across facilities in our base scenario. Staff costs per newborn are Capital Costs with important economies of scale: highest in small facilities (US$ 482) and lowest in medium units (US$ 365) Facility Capital Costs (Total & per Bed) USD (‘000) Other costed facility-level Quality of Care strategies, such as recurrent funding for referral ✓ Small: $ 488 total & $ 54 per bed support systems, are critical, but relatively ✓ Medium: $ 555 total $ 46 per bed low-cost when compared to other components ✓ Large: $716 total & $40 per bed of the scale-up. National investments to strengthen Quality of Significant recurrent costs to ensure good quality Care include higher education courses for nurses of care with higher costs per bed for small units. and doctors. Their annual costs amount to over US$ 400 thousand. Facility Recurrent Costs (Total & per Bed) Other national and regional strategies to USD (‘000) provide management, oversight, and support to the scale-up involve one-off costs of US$ 280 ✓ Small: $ 251 total & $ 28 per bed thousand and subsequent annual costs of US$ 40 ✓ Medium: Recurrent costs$ 265 are total $ 22 ranging significant, per bed fr thousand. ✓ Large: $ 400 total & $ ✓ om US$ 251 thousand for a small22 per bed facility to over US$ 400 thousand for a large unit. We hope this analysis aids high-level discussions, including decisions on the strategic scope of the scale-up, such as a focus on a larger number of Across various scenarios, when looking at facilities of smaller size vs fewer facilities of individual core components, we find: larger size and catchment areas. Construction prices can have a significant In a sense, our analysis articulates explicitly impact on capital costs. For example, new the pre-conditions of the theory of change construction costs for a large facility range from behind the success of scaling-up small and sick US$ 228 to US $341 thousand across various cost newborn care in Zambia. locations. We hope this prompts an in-depth review of the facility standards and implementation For equipment & commodities: considerations that have informed our costing ✓ Equipment acquisition prices vary exercise. significantly and have a large impact. The P a g e |2 CONTENTS EXECUTIVE SUMMARY ............................................................................................................................ 1 INTRODUCTION ....................................................................................................................................... 3 THE COSTING TOOL & COUNTRY DATA .................................................................................................. 3 THE COSTS OF SETTING-UP SMALL AND SICK NEWBORN CARE UNIT .................................................... 5 Capital & Recurrent Costs for small, medium & large units ............................................................... 5 Infrastructure ...................................................................................................................................... 7 Equipment & Commodities ................................................................................................................. 8 Human Resources ............................................................................................................................. 10 Quality of Care Strategies ................................................................................................................. 11 National & Regional Strategies ......................................................................................................... 11 WHAT NEXT FOR ZAMBIA? ................................................................................................................... 12 REFERENCES .......................................................................................................................................... 13 ANNEXES ............................................................................................................................................... 14 A1 – Infrastructure Standards ........................................................................................................... 14 A2 – Equipment - Standards & Prices ............................................................................................... 16 A3 – Human Resources - Standards & Salaries ................................................................................. 24 A4 – Facility Base Scenario Results ................................................................................................... 25 A5. Small and Sick Newborn Care Costing Workshop – Lists of Participants ................................... 26 P a g e |3 INTRODUCTION The health system requirements to enable the We used various typologies of facilities to capture fulfilment of WHO standards and the associated cost variations across the country, which allows guidelines for the scale-up of Small and Sick us to unpack key cost drivers and their impact on Newborn Care Units have not been costed. budgets. We have also accounted for the expected impact that setting up a new facility has on With a view to estimate a realistic budget that recurrent expenditure. supports good quality of care, as prescribed by their own standard and guidelines, countries We hope the report results and the populated need to be able to unpack what it takes and how costing tool will aid the development of a robust much it would cost to scale-up services. strategy for the scale-up of Small and Sick Newborn Care Units in Zambia. This report presents the key results of a costing exercise undertaken in Zambia during the second The remaining of the report is organised as half of 2022. follows: After a summary description of methods, key results are briefly discussed, followed by To estimate the cost of putting in place all the conclusions. Detailed information on system required elements to scale-up good quality of parameters modelled as well as detailed cost care, we used a Beta Version of an Excel-based results are presented in Annexes A1 to A4. Annex costing tool developed by GFF. The tool has been A5 lists the stakeholders who attended a country populated using local data collected and workshop and developed the revised list of validated in country. system standards that informs our modelling. THE COSTING TOOL & COUNTRY DATA The GFF costing tool uses normative costings to individual facilities and allocate limited budgets examine how much it would cost and what it according to their priority ranking. would take to scale-up good quality of care for small and sick newborns, delivered at Level I A The first task under each planning and budgeting district facilities (Zambia standards). We note module is to setup step-by-step the relevant that in the international literature these are country standards and requirements for usually classified as Level II facilities. implementation, which provide the normative system parameters for costing. Global evidence on best-practice (1) (2) (3) (4) (5) (6) (7) (8), and implementation lessons drawn We sourced facility standards from existing from a case study of Haryana, India (9), a setting national guidelines (10) (11) for 9-bed (small), where the scale-up was directly managed by the 12-bed (medium) and 18-bed (large) units. government were used to inform the tool development. Unfortunately, some of the current guidelines and standards lack enough detail to inform actual To produce a comprehensive set of costings, the implementation and realistic costings. For tool includes planning and budgeting modules example, they recommend that in addition to for infrastructure; equipment and commodities; nurses, all units should have medical doctors and human resources; quality of care strategies; as support staff such as nutritionists. (10) However, well as regional and national strategies required there is no information on what their required to effectively manage and support the scale-up. numbers would be, which is critical for human resource planning, costing, and budgeting. An optional prioritisation module is also included, though it has not yet been used in To fill this gap we drew on the Haryana case Zambia. This module allows users to cost study and available guidelines for India, (4) Bangladesh, (5) Sierra Leone, (7) and South P a g e |4 Africa (6) and produced a detailed list of system identified data gaps that should be addressed for parameters. They were validated by stakeholders providing realistic costings. representing the DoH, development partners and service delivery staff at a country workshop in During the following months, representatives Lusaka on October 25th 2022 (Annex 5). from the government, GFF and UNICEF Zambia collaborated online to validate existing cost data Since one of our objectives is to support and assemble the additional inputs required to discussions on ‘what it takes’ to scale-up good cost items such as equipment transport and quality of care, the detailed standards were consumables. Validated data for key costing presented at the meeting and their costing parameters is presented in the corresponding implications discussed. As expected, this led to Annexes or discussed in the relevant sections of robust discussions and substantial revisions to the report. A more detailed documentation of all the proposed facility standards were agreed at data and assumptions is used is included in the the meeting. populated costing tool. The agreed list of infrastructure standards, Since costs are likely to vary substantially across including number of beds and floor standards are facilities, due to factors such as size and location, detailed in Annex A1. The relevant equipment the tool uses typologies to account for such in- and staff ratios are included in Annex A2 and A3. country cost variations. Five typologies (facility size, location, equipment needs, type of As noted in the annexes, stakeholders added construction and recruitment) with up to three system standards for 36-bed units, which in some different categories each have been included in cases were assumed to be double the required the tool. The mix and match can produce many numbers for an 18-bed facility. However, due to ‘unique’ alternative typologies for which costs time constraints there was insufficient can be estimated and assigned to individual discussion about factors that could lead to facilities based on those characteristics. economies or diseconomies of scale. So these facilities are excluded from the current analysis. For this report we focus on selected typologies to explore the salient system and cost implications A national consultant was engaged to collect of decisions that policymakers and investors costing data on key parameters such as would normally face when planning and equipment and staff salaries prior to the budgeting for the scale-up. workshop. This involved reviewing government documentation such as staff salaries and Those interested in more detailed results and allowances regulations, interviewing key further modelling are referred to the tool with informants, as well as sourcing equipment prices the uploaded Zambia data, which includes data directly from twelve different vendors. and modelling results for all five typologies and associated categories. Stakeholders were unable to validate costing parameters on the spot, but the discussions flagged important parameters for validation and P a g e |5 THE COSTS OF SETTING-UP SMALL AND SICK NEWBORN CARE UNIT We examine below the overall costs of setting-up Costs were estimated from the budget holder’s Small and Sick Newborn Care Units of different perspective and all results are presented in USD sizes, followed by a review of costs associated (2022), using an exchange rate of 1 Kwacha = 17 with individual scale-up components. USD. C APITAL & R ECURRENT C OSTS FOR SMALL , MEDIUM & LARGE UNITS We present costings of a base scenario for three facility sizes: ✓ The remaining capital costs are represented by acquisition of an ambulance to support ✓ Small: 9 beds & 375 annual newborn referrals. admissions ✓ Medium : 12 beds & 495 admissions ✓ There are important economies of scale. ✓ Large: 18 beds & 750 admissions. Capital costs per bed for a large facility are 14% lower than those modelled for a medium facility and 27% lower than those In our base scenario infrastructure costs are for for a small one. new construction and all the required equipment, while human resources are costed for Recurrent Costs standard recruiting areas. ✓ Recurrent costs are significant across all We modelled three-point cost estimates for facilities. They range from US$ 251 thousand construction, equipment and quality of care for a small facility to over US$ 400 thousand strategies to capture cost variations across for a large unit. locations. We acknowledge that investments in quality of care are costly, so we have named these ✓ As expected, human resources account for location typologies mid-cost (rather than low most of the recurrent expenditure, cost), high-cost and very high-cost. representing approximately 68% to 73% across facilities. Unless indicated otherwise, we use the high-cost typology which represents a middle cost point in ✓ The remaining recurrent costs are mostly the country. related to equipment and commodities, Our modelling results, summarised in Figures 1 which are discussed in more detail in the and 2 and detailed in Annex A4 show that: following sections. Capital Costs ✓ When looking at costs per bed, medium-size and large facilities show similar recurrent ✓ One-off capital costs are substantial and go costs. Both have recurrent costs per bed 20% from US$ 487 thousand for a small facility to lower than 9-bed facilities. US$ 717 thousand for a large unit. ✓ Broadly similar results are observed when ✓ All equipment costs account for looking at costs per newborn admitted (See approximately 50% of capital costs across detailed base scenario results in Annex A4). the three facilities. This suggests that based on currently modelled facility standards, there are ✓ New construction as per the required important inefficiencies for smaller facilities. standards account for 34% and 35% for small and medium units and 40 % of capital costs large facilities. P a g e |6 Figure 1 – Total Facility Costs by Typology - Capital & Recurrent (USD 2022) Total Facility Costs by Typology (USD 2022 ) $716,295 $555,025 $487,278 $399,518 $250,999 $264,837 Small Medium Large FACILITY CAPITAL COSTS FACILITY RECURRENT COSTS Figure 2 - Facility Costs per Bed by Typology - Capital & Recurrent (USD 2022) Facility Costs per Bed by Typology (USD 2022) $54,142 $46,252 $39,794 $27,889 $22,070 $22,195 Small Medium Large Capital Cost per Bed Annual Cost per Bed P a g e |7 I NFRASTRUCT URE We modelled how much it would cost the new Infrastructure costs are also driven by facility construction of a facility as per the infrastructure floor standards, in particular the required space standards summarised in Annex A1. We sourced per bed, which varies by type of bed (Annex A1). cost per square meter from a key informant at the DoH. Costs were triangulated against available ✓ In-patient areas account for approximately construction data, including for a tertiary 38% to 44% of total floor space across the hospital in Lusaka (12) and validated by the three facility sizes. Department of Health. ✓ There are important economies of scale, Our base scenario uses a point estimate of mostly driven by the required minimum US$600 per square meter of new construction. space for other facility areas, which as expected do not increase in line with the Two additional estimates of US$ 480 and US $720 number of beds (Annex A1). per square meter are also used to test the sensitivity of the results to construction prices ✓ Circulation space standards, such as those and illustrate the variation of costs that could be related to corridors and entrance, would also expected across different locations in Zambia. affect total construction costs. Based on stakeholder discussions, we use a Our results summarized in Figure 3 show: conservative estimate of circulation space ✓ As expected, construction prices can have a equivalent to 10% of total floor space vs. significant impact with total new 30% in Haryana. construction costs ranging from: Although results are not shown here, we also ▪ US$ 132 to US$ 198 thousand (9-bed modelled costs for facilities in need of unit) rehabilitation, available in the populated costing ▪ US$ 156 to US $234 thousand (12-bed tool. We use the assumption of approximately unit) 60% of new construction costs based on data ▪ US$ 228 to US $341 thousand (18-bed from the Haryana case study. (9) unit) Figure 3 – Facility Building – New Construction Costs per Bed (USD 2022) Building - New Construction Costs per Bed (USD 2022) Mid Cost High Cost Very High Small $14,667 $18,333 $22,000 Medium $13,024 $16,280 $19,536 Large $12,643 $15,803 $18,964 P a g e |8 E QUIPMENT & C OMMODITIES We costed one-off and recurrent costs associated maximum price equivalent to 6.3 times the with Equipment & Commodities. Under capital minimum price. costs we have included medical equipment acquisition value as well as transport, ✓ Pulse oximeters and oxygen concentrators distribution and installation costs; furniture and have lower individual prices and so smaller other equipment; and the cost of a new absolute differences, but maximum prices ambulance. Recurrent costs include those are 44 and 21 times higher than minimum associated with maintenance, consumables and prices, respectively. renewables, other medical supplies, and ambulance referral expenses. Although market factors might be at play, such large differential most likely reflects different One-off Capital Costs specifications & quality. Robust procurement systems, including detailed specifications for To cost purchasing the required equipment we tenders are required to ensure good quality and sourced prices for 65 major pieces of equipment good value for money. identified in national guidelines from twelve vendors (Annex A2). Though we requested prices As shown in Figure 4, in line with such large price inclusive of a three-year warranty, only one year differences, the total cost of equipping a facility at was offered. Transport and installation costs minimum prices is approximately half the cost of were not included and have been estimated a scenario estimated using maximum prices. separately, based on information provided by UNICEF Zambia. Across various scenarios, even after excluding shared equipment (mobile X Ray and blood gas Equipment price data provided in Annex A2 analyser), a few items account for approximately shows that there are significant variations in 50% of equipment costs. These include individual equipment prices, also found in recent resuscitaire, ventilators, oxygen concentrators, reports. (12) Of note: phototherapy units and closed incubators. ✓ The largest price difference is observed for mobile X-rays (US$ 27,831) with the Figure 4* – The Cost of Purchasing Facility Equipment (USD 2022) Purchasing Facility Equipment @ Different Prices (USD 2022) $300,000 $250,000 $200,000 $150,000 $100,000 $50,000 $0 Small (9) Medium (12) Large (18) @ Minimum Price $82,652 $97,293 $129,593 @ Base Price $158,787 $182,750 $231,997 @ Maximum Price $179,857 $209,474 $267,418 Note: A base price is equivalent to the mid-point price available, although in cases where only two prices were available, the maximum price was used. P a g e |9 As shown in Table 1, summarising results for our down at an individual facility. In line with base scenario, equipment acquisition costs are recommendations from UNICEF head office, only the tip of the iceberg. buffer stocks equivalent to 10% of equipment acquisition and transport costs were included. Other significant one-off costs include transport, installation, and distribution costs, which can range across cost location typologies from 20 to To support in-referrals from lower level facilities 40% of equipment acquisition value. We have and communities, as well as out-referrals, the used a 30% estimate for our base scenario. cost of an ambulance vehicle has also been included. The cost shown in Table 1 does not We also costed buffer stocks to be managed at include the required equipment, which was regional level to ensure a replacement is costed separately. available when a piece of equipment breaks Table 1 – One-Off Equipment & Vehicle Costs by Facility Size Typology (USD 20222) Facility Equipment & Vehicle – Small Medium Large Capital Costs (USD) (USD) (USD) Equipment Acquisition $158,787 $182,750 $231,997 Equipment Distribution & Installation $47,636 $54,825 $69,599 Equipment Buffer Stocks $19,054 $21,930 $27,840 Furniture & other Equipment $16,800 $20,160 $22,400 Ambulance Vehicle $80,000 $80,000 $80,000 Total Equipment & Vehicle Costs $322,278 $359,665 $431,835 Recurrent Costs ✓ Across various scenarios approximately Recurrent costs associated with equipment and three quarters of equipment recurrent costs commodities were estimated, mostly based on are represented by consumables and information provided by UNICEF Zambia office, renewables. drawing on their locally funded projects and validated against their recent experience in India. ✓ Costs of consumables and renewables per Of note: newborn admitted decrease with facility size. They are expected to range from: ✓ Costs are likely to vary by location and it has been estimated that annual expenditure on ▪ US$ 105 to US $140 for 9-bed facilities consumables and renewables represent ▪ US$ 94 to US$ 125 for 12-bed facilities between 30 to 40% of the equipment ▪ US$ 78 to US$ 104 for 18-bed facilities acquisition value. We have not been able to secure country data on ✓ It is expected that an additional annual the recurrent costs of medicines, which are not expenditure equivalent to 10%-15% of included above. However anecdotal evidence equipment acquisition value would be seems to suggest that they represent a relatively required each year for maintenance. small proportion of other medical supplies costs such as consumables and renewables. For this ✓ As shown in Figure 5, after adjusting for costs exercise we are assuming an additional cost per of shared equipment, annual expenditure is newborn admitted of U$ 8, which would need expected to range from US$ 53 thousand for further validation in-country. a 9-bed facility in a mid-cost location to US$107 thousand for an 18-bed facility in a very high-cost location. P a g e | 10 Figure 5 – Recurrent Costs of Equipment & Commodities (USD 2022) Recurrent Costs of Equipment & Commodities (USD 2022) $107,126 $91,545 $85,088 $77,911 $71,908 $72,712 $61,449 $61,883 $52,297 Small Medium Large Mid-cost High-cost Very high-cost H UMAN R ESOURCES Staff costs represent the largest expected annual ✓ Annual staff costs are the same for small and expenditure for individual facilities. In addition medium facilities since there was consensus to salaries and allowances, we also included in- that the same staff ratios should be applied. service training and supervision visits, which are Note that for rural and remote areas where critical for ensuring good quality of care, but hardship allowances apply costs will be 20% represent barely 2% of total human resources and 25% higher. expenditure. Other training costs are significant, but they are modelled at national level. ✓ As expected, since 12-bed facilities would be delivering services for a higher number of Facility staff costs were modelled based on newborns than 9-bed units, costs per stakeholders’ decisions on the staff numbers newborn are substantially lower, even lower required to deliver good quality of care at each than those for 18-bed units. facility. As documented in Annex A3, required human Our estimates also suggest that: resources include not only health staff, but also support personnel required for effective referral ✓ Nurses account for 34 % of salaries in large systems, infection and prevention control, units vs. 42% for small and medium. maintenance and quality of care more generally. ✓ Medical personnel represent 21% of salaries As noted earlier, original numbers provided by in large facilities vs. 15% for the other two. GFF, based on the case study and national international guidelines were substantially ✓ As a result of the large number of required reviewed by workshop participants, based on nutritionists (4 for 9-bed and 12-bed units & their clinical experience and other 8 for 18-bed units) they account for 11% to considerations such as number of working hours 13% of staff costs. per shift. Though discussions were robust, there were time constraints that prevented a thorough ✓ Security guards and cleaners account for review of agreed standards. 13% to 16% of salary costs. As shown in Table 2: P a g e | 11 Table 2 – Staff Costs for Standard Recruiting Areas by Facility Size (USD 2022) Facility Staff Costs Small Medium Large (USD) (USD) (USD) Total Staff Costs $180,804 $180,804 $290,934 Salaries $177,108 $177,108 $285,753 Development $3,696 $3,696 $5,181 Staff Costs per newborn admitted $482 $365 $388 Q UALITY OF C ARE S TRATEGIES An important number of Quality of Care community and out-referrals to higher facilities. strategies are costed under separate headings, Since salaries for one driver per facility are such as ensuring adequate infrastructure, included in human resource costs, we only equipment and human resources. However, the estimated ambulance fuel and maintenance costing tool provides a default menu of Quality of costs. Annual estimates range from $3.4 Care strategies to ensure they are given due thousand for a 9-bed facility in a mid-cost consideration when planning and budgeting for location to $8.4 thousand in an 18-bed unit in a the scale-up and do not fall through the cracks. very high-cost location. In addition to those examined above, our Further in-country discussions might suggest modelling also includes building maintenance additional quality strategies that need to be costs equivalent to 1% of a new building value, implemented and costed. For example, we were which given the significant recurrent costs unable to cost information and communication associated with human resources and campaigns targeting the community to ensure equipment, represent less than a half percentage timely access, referrals and good quality follow- point of estimated recurrent costs. up care. Access to alternative sources of electricity and water were neither included in We also estimated the recurrent costs for our strategies and costs. referrals, which are required to ensure adequate in-referrals from lower facilities and the N ATIONAL & R EGIONAL S TRATEGIES Improving quality of care while scaling-up Diploma and a Master of Science in Neonatology district facility services for small and sick for nurses, as well as a Postgraduate Diploma in newborns entails system changes across multiple Neonatology for doctors (10 students enrolled in domains and levels. each course every year). Effective local solutions to local problems must We also included costs related to: be supported by high-level systems, for example for assets management, and national oversight of ✓ commissioning of infrastructure and the scale-up. equipment including development of detailed equipment specifications ($60 The costing tool includes a default menu of thousand in year 1); strategies that we have used to estimate national ✓ development of national guidelines and and regional costing summarized in Figure 6. templates ($ 120 thousand in year 1) Higher Education Training costs (over U$ 400 ✓ Continuous quality of care strategies, thousand a year) includes annual tuition fees and including monitoring and evaluation and scholarship allowances for one Advanced supporting the development of facility P a g e | 12 systems for reporting adverse events ($100 covered by national programs targeting the thousand in year 1 plus additional annual health sector in general. costs of $40 thousand). ✓ Other costs related to high-level ✓ For supply chain management, we have management and oversight of the scale-up assumed no additional costs as they could be have not been included since their costing requires a defined strategy, still to be developed. Figure 6 – National & Regional Level Costs (USD 2022) National and Regional Level Costs (USD 2022) $404,950 $404,950 $280,000 $40,000 Costs First Year (2023) Annual Costs in Subsequent Years National and Regional Strategies Higher Education Courses for Health Staff WHAT NEXT FOR ZAMBIA? Our results indicate that, as expected, scaling-up which are both influenced by what it takes for a facility care for small and sick newborns requires facility to operate according to the national substantive investments in infrastructure, standards and guidelines. equipment, human resources and quality of care more generally. We hope this analysis aids high-level discussions such as those on the scale-up of the scope and Recurrent costs can be significant and should be alternative facility standards. given due consideration in terms of sustainability and efficient use of resources. We have taken advantage of the fact that our costing approach, like actual implementation, High-level discussions on the strategic scope of requires an explicit articulation of the specifics of scaling-up services are necessary to ensure the standards and strategies for scaling-up care for right facilities are set-up in the right places, small and sick newborns. supported by strong referral networks and adequate regional and national systems. This In a sense, our approach makes explicit the pre- involves decisions such as whether to fund a conditions of the scale-up, which we hope will larger number of smaller facilities or financing prompt a review of the facility standards and fewer facilities of larger sizes and catchment implementation considerations that underlie not areas. only our costings, but the success of scaling-up good quality of care. Such decisions need to be informed by realistic costings and implementation considerations, P a g e | 13 REFERENCES 1. WHO. Standards for improving quality of care Limpopo : Limpopo Department of Health and for small and sick newbons in health facilities. University of Limpopo, 2013. Geneva : WHO, 2020. 7. Global Expert Consulation of a Generic Model for 2. —. Human resource strategies to improve Inpatient Care of Small and or Sick. WHO & newborn care in health facilities in low- and UNICEF. Geneva : WHO & UNICEF, 2021. middle-income countries. Geneva : WHO, 2020. 8. NEST360. Newborn Implementation Toolkit. 3. —. Survive and thrive: transforming care for [Online] 2022. every small and sick newborn. Geneva. Geneva : https://www.newborntoolkit.org/toolkit. WHO, 2019. 9. Trikka, Sonja. Caring for Small and Sick 4. Indian National Neonatology Forum, UNICEF. Newborns - India Experience. s.l. : Unpublished, Toolkit for Setting Up Special Care Newborn Units, 2022. Stabilisation Units and Newborn Care Corners. New Delhi : UNICEF, 2011. 10. Republic of Zambia, Ministry of Health. Service Standards for Health Institutions Providing 5. UNICEF, WHO and Bangladesh Neonatal Forum. Neonatal Care in Zambia. Lusaka : s.n., 2020. Standard Operating Procedures for Newborn Care Services at Primary and Secondary Level Hospital. 11. —. Standards for Improving the Quality of Dhaka : UNICEF, 2014. Health Care for Small and Sick Newborns in Health Facilities in Zambia (DRAFT). Lusaka : s.n., 2022. 6. Limpopo Initiative for Newborn Care. Norms and Standards for Essential Neonatal Care. 12. Perez, APC. Neonatal Intensive Care Unit 100 Essential newborn care implementation toolkit. Percent Design Report. Washington, DC : USAID, 2020. P a g e | 14 ANNEXES A1 – I NFRAST RUCT URE S T ANDARDS Table A.1.1. Facility Sizes & Number and Type of Beds Types of beds Small Medium Large Extended* All Inpatient Beds 9 12 18 36 High-Care Beds 2 3 4 8 Standard Inpatient Care 3 3 6 12 Kangaroo Mother Care Beds 4 6 8 16 *Distribution of beds modified in 2024 following the 18-bed unit mix of beds Table A.1.2. Minimum Floor Space per Type of Bed Types of beds Sq. Mt per Bed High-Care Beds 10 Standard Inpatient Care 12 Kangaroo Mother Care Beds 12 P a g e | 15 Table A.1.3 Minimum Floor Space per Area by Facility Size Other Facility Service Areas Small Medium Large Extended (9 beds) (12 beds) (18 beds) (36 beds) Triage/receiving room 12 12 20 30 Counselling area 0 0 0 12 Family facilities (exc. lodger mother beds) 8 8 12 30 Lodger Mother Beds 24 36 48 96 Nursing station 10 10 15 20 Nurses & doctors rest areas 8 8 12 20 Pantry with dining area 0 0 0 30 Storage unit 7 7 10 15 Clean utility 7 7 10 15 Dirty utility 7 7 10 15 Neonatal unit office 10 10 15 20 Meeting room 20 20 30 30 P a g e | 16 A2 – E QUIPMENT - S TANDARDS & P RICE S Table A.2.1 Type of Equipment and Requirements per Facility Size* Equipment_Name Small Medium Large Extended Notes from National Service Standards (2020) (9 beds) (12 beds) (18 beds) (36 beds) General Equipment Closed incubator 3 4 6 12 1 per 3 neonates Bassinet (washable) 9 12 18 36 1 per SIC bed & KMC: Bassinets/cribs Transport incubator 2 2 2 2 Overhead servo incubator 2 3 4 8 1 per HC bed Heat shield 2 3 4 8 1 per HC bed Wall suction unit 3 4 6 12 1 per suction point Phototherapy units 4 6 8 12 1 per 5-unit beds KMC: Phototherapy machines for jaundiced babies Transcutaneous bilirubinometer 1 1 1 2 1 per unit Electronic Scale 3 3 4 6 1 per unit cubicle & KMC requirements Glucometer 4 4 4 6 1 per unit & ambulance, KMC and triage requirements Thermometer 10 13 19 37 1 per baby & KMC and triage requirements Equipment for respiratory support and oxygen therapy Nasal CPAP (complete) 4 5 6 10 1 per HC bed & Ambulance and triage requirements Head boxes 0 0 0 0 1 per SIC & HC bed Pulse oximeters 10 13 19 37 1 per HC bed & 1 per 2 SIC beds & ambulance, KMC and triage requirements Oxygen flow meter 9 12 18 36 1 double per unit bed Oxygen cylinders 4 5 8 16 1 double per unit bed & ambulance P a g e | 17 Equipment_Name Small Medium Large Extended Notes from National Service Standards (2020) (9 beds) (12 beds) (18 beds) (36 beds) Oxygen concentrators 10 13 19 37 1 double per unit bed & ambulance requirements Oxygen blender 2 3 4 8 1 per HC bed Oxygen analyser 1 2 2 4 1 per 2 HC bed Apnoea monitors 2 3 4 6 1 per 2 HC bed Trans illumination light 1 1 1 1 1 per unit & KMC and triage requirements Chest drain kit 1 1 1 2 1 per unit and triage requirements Fluid controllers and cardiac monitors Intravenous infusion controllers 2 2 2 4 1 per unit & ambulance requirements Multiparameter monitors 2 3 4 8 1 per HC bed BP monitor - portable 3 4 5 9 1 per HC bed & KMC requirements Shared Equipment Mobile X Ray (digital as per 1 1 1 1 1 in the hospital specification pp. 143) Blood gas analyser 0 0 1 1 1 in large hospitals Resuscitation equipment Note: In general requirements for ambulance Resuscitaire 2 2 2 4 1 per unit & KMC requirements Portable neonatal suction 2 2 2 4 1 per unit Advanced Resuscitation trolley 1 1 1 2 1 per unit & KMC requirements Laryngoscope, straight miller blade 3 3 3 4 1 per advanced resuscitation trolley & KMC size 00,0, spare batteries and bulb requirements McGill's forceps 2 2 2 2 1 per advanced resuscitation trolley & triage requirements Other Listed separately in national guidelines Transport ventilators 1 1 1 1 Ambulance P a g e | 18 Equipment_Name Small Medium Large Extended Notes from National Service Standards (2020) (9 beds) (12 beds) (18 beds) (36 beds) One drip stand 3 3 3 3 Ambulance & triage requirements Wall Mounted television set or 1 1 1 1 KMC requirements educational material educational video tapes or flash 1 1 1 1 KMC requirements drivers Upright fridge for the mothers 1 1 1 2 KMC requirements Microwave 1 1 1 2 KMC requirements Bucket for decontamination 3 3 3 6 KMC requirements Heaters/ air conditioners 6 6 6 10 KMC & triage requirements Wall thermometer 2 4 4 8 KMC requirements Stethoscope 11 14 20 38 KMC & triage requirements Suction machine 1 1 1 2 KMC requirements Penguin Suckers 1 1 1 2 KMC requirements Oxygen gauge 1 1 1 1 KMC requirements Infantometer 2 2 2 2 KMC & triage Equipment Hand held hearing screening device 1 1 1 1 KMC requirements (auto-acoustic Emission) Pen torch 2 2 2 2 KMC & triage requirements Tourniquet 1 1 1 1 KMC requirements Infusion pumps 2 2 2 2 KMC & triage requirements Ventilator 1 1 1 1 Triage requirements Nebulizer 1 1 1 1 Triage requirements Emergency trolley 1 1 1 1 Triage requirements Syringe pumps 1 1 1 1 Triage requirements Screens 1 1 1 1 Triage requirements P a g e | 19 Equipment_Name Small Medium Large Extended Notes from National Service Standards (2020) (9 beds) (12 beds) (18 beds) (36 beds) Sharps box 1 1 1 1 Triage requirements Diagnostic set (otoscope and 1 1 1 1 Triage requirements ophthalmoscope) Paediatric BP machine with all the 1 1 1 1 Triage requirements different cuff sizes (neonate, infant, child) Neonatal resuscitation emergency 1 1 1 1 Triage requirements trolley with all drugs required for advanced neonatal resuscitation. Basic monitor (Pulse oximeter, 1 1 1 1 Triage requirements Pulse rate, blood pressure and temperature). Oxygen masks. 1 1 1 1 Triage requirements Drums 1 1 1 1 Triage requirements Desktop Autoclave machine 1 1 1 1 Triage requirements stainless steel cheatle forceps and 1 1 1 1 Triage requirements holder Adult stethoscope 3 3 3 3 Not in national standards Digital adult weighing scale 3 3 3 3 Not in national standards Laryngoscope (with adult blades) 3 3 3 3 Not in national standards Equipment maintenance toolbox 1 1 1 1 Not in national standards *Requirements for 36-bed unit modified in 2024 to reflect the new distribution of beds P a g e | 20 Table A.2.2 Available Equipment Prices from Country Suppliers (US Dollars, 2022) Equipment_Name Minimum Medium Maximum Price (USD) Price (USD) Price (USD) General Equipment Closed incubator $1,835 $3,912 Bassinet (washable) $321 $518 Transport incubator $1,193 Overhead servo incubator $1,618 Heat shield $105 Wall suction unit $226 $915 Phototherapy units $1,324 $1,832 $2,353 Transcutaneous bilirubinometer $457 Electronic Scale $265 $382 $882 Glucometer $15 $34 $46 Thermometer $4 $5 $18 Equipment for respiratory support and oxygen therapy Nasal CPAP (complete) $735 $1,471 $2,744 Head boxes NA NA NA Pulse oximeters $21 $550 $915 Oxygen flow meter $71 $81 Oxygen cylinders $28 $588 Oxygen concentrators $912 $1,324 $1,794 Oxygen blender $1,441 Oxygen analyser $247 Apnoea monitors $188 P a g e | 21 Equipment_Name Minimum Medium Maximum Price (USD) Price (USD) Price (USD) Trans illumination light $62 $144 $424 Chest drain kit $44 Fluid controllers and cardiac monitors Intravenous infusion controllers $735 Multiparameter monitors $1,471 $2,029 $2,824 BP monitor - portable $29 $38 Shared Equipment Mobile X Ray (digital as per specification pp. 143) $5,588 $35,056 Blood gas analyser $11,471 Resuscitation equipment Resuscitaire $3,824 $4,029 $4,235 Portable neonatal suction $26 Advanced Resuscitation trolley $1,324 Laryngoscope, straight miller blade size 00,0, spare batteries and bulb $176 $232 McGill's forceps $8 $24 Other Transport ventilators $1,912 $8,529 One drip stand $16 $76 $100 Wall Mounted television set or educational material $434 educational video tapes or flash drivers $9 Upright fridge for the mothers $512 Microwave $147 Bucket for decontamination $6 Heaters/ air conditioners $529 P a g e | 22 Equipment_Name Minimum Medium Maximum Price (USD) Price (USD) Price (USD) Wall thermometer $4 $18 Stethoscope $26 $92 Suction machine $203 $529 Penguin Suckers $17 $29 Oxygen gauge $39 $74 Infantometer $15 Hand held hearing screening device (auto-acoustic Emission) NA NA NA Pen torch $7 $18 Tourniquet $18 Infusion pumps $420 $853 $1,588 Ventilator $9,870 $11,324 Nebulizer $42 $191 $235 Emergency trolley $276 $1,765 Syringe pumps $360 $2,647 Screens $115 $176 Sharps box $2 $4 Diagnostic set (otoscope and ophthalmoscope) $174 $1,524 Paediatric BP machine with all the different cuff sizes (neonate, infant, child) $26 $85 Neonatal resuscitation emergency trolley with all drugs required for advanced neonatal $1,324 resuscitation. Basic monitor (Pulse oximeter, Pulse rate, blood pressure and temperature). $554 $2,029 Oxygen masks. $2 $6 Drums $85 Desktop Autoclave machine $3,676 P a g e | 23 Equipment_Name Minimum Medium Maximum Price (USD) Price (USD) Price (USD) Stainless steel cheatle forceps and holder $14 $50 Adult stethoscope $26 $29 Digital adult weighing scale $53 $74 Laryngoscope (with adult blades) $118 $232 Equipment maintenance toolbox NA NA NA P a g e | 24 A3 – H UMAN R ESOURCES - S TANDARDS & S ALARIES Table A3.1 Required Staff Categories and FTE Numbers by Facility Size Staff Category Small Medium Large Extended Neonatologist 0 0 0.3 1 Medical Officer 1 1 2 4 Medical Licentiates 1 1 2 2 Clinical Officers 1 1 1 0 Registered Paediatric/Neonatal Nurses 8 8 10 20 Registered Nurses 4 4 5 10 Midwives 1 1 2 4 Administrative/clerical staff 1 1 1 2 House Keepers 4 4 8 8 Infection Control Staff 1 1 1 1 Data Registry Clerk 1 1 1 2 Nutritionist/Nutritional Demonstrators 4 4 8 8 Bio-medical technologists 0.5 0.5 1 1 Security Guards 3 3 6 6 Drivers 1 1 1 2 Ambulance Call Centre Staff 0.5 0.5 0.5 0.5 *Nurse requirements for Extended (36-bed unit) modified in 2024 to reflect the new distribution of beds Table 3.2 Required Staff – Annual Salaries, including allowances (except hardship) Staff Category Annual Salaries & Allowances (USD 200) Neonatologist $25,917 Medical Officer $25,917 Medical Licentiates $7,533 Clinical Officers $5,386 Registered Paediatric/Neonatal Nurses $5,897 Registered Nurses $5,386 Midwives $5,897 Administrative/clerical staff $4,918 House Keepers $3,260 Infection Control Staff $5,386 Data Registry Clerk $3,785 Nutritionist/Nutritional Demonstrators $4,783 Bio-medical technologists $4,783 Security Guards $3,260 Drivers $3,423 Ambulance Call Centre Staff $3,598 P a g e | 25 A4 – F ACILITY B A SE S CENARIO R ESULTS Table A4.1 Base Scenario* – Summary of Facility Service Parameters & Costs Service Parameter/Cost Small Medium Large Expected annual number of admissions (#) 375 495 750 Number of beds required (#) 9 12 18 Total floor space (Sq. Mts.) 275 326 474 FACILITY CAPITAL COSTS (Total) $487,278 $555,025 $716,295 Building $165,000 $195,360 $284,460 Equipment $242,278 $279,665 $351,835 Equipment Acquisition $158,787 $182,750 $231,997 Equipment Distribution $47,636 $54,825 $69,599 Equipment Buffer Stocks $19,054 $21,930 $27,840 Furniture and other $16,800 $20,160 $22,400 Ambulance Vehicle $80,000 $80,000 $80,000 FACILITY RECURRENT COSTS (Total) $250,999 $264,837 $399,518 Human Resources $180,804 $180,804 $290,934 Salaries $177,108 $177,108 $285,753 Development $3,696 $3,696 $5,181 Equipment $61,449 $72,712 $91,545 Regular Maintenance $15,689 $18,565 $23,374 Consumables & Renewables $45,760 $54,147 $68,171 Other $8,747 $11,321 $17,038 Ambulance Referral $3,797 $5,012 $7,594 Building maintenance $1,650 $1,954 $2,845 Other $3,300 $4,356 $6,600 FACILITY CAPITAL COSTS Capital Cost per Bed $54,142 $46,252 $39,794 Building 34% 35% 40% Equipment 50% 50% 49% Ambulance Vehicle 16% 14% 11% FACILITY RECURRENT COSTS Annual Cost per Bed $27,889 $22,070 $22,195 Annual Cost per Newborn Admission $669 $535 $533 Human Resources 72% 68% 73% Equipment 24% 27% 23% Other 3% 4% 4% Typologies used for Base Scenario: New Construction, Major Equipment Needs (100%), High-cost Location (i.e. mid- point of cost estimates) and Standard Recruitment Area (i.e. no hardship allowances). Facility Equipment costed at base prices. P a g e | 26 A5 - S MALL AND S ICK N EWBORN C ARE C OSTING W ORKSHOP – L IST S OF P ARTICIPANTS Table A5.1 List of Small and Sick Newborn Care Costing Workshop Participants NAME DESIGNATION INSTITUTION Alison Morgan Senior Health Specialist GFF Gae C.N Mundundu Newborn Care National MOH Coordinator Apurva Chaturvedi Health Specialist UNICEF UNICEF Selia Ng’anjo Obstetrician/Gynaecologist WNH-UTH Mervis Pepino Public FinanceAssociate UNICEF UNICEF Mary Nambao Liaison Officer GFF Aya Kagota Health specialist World Bank Sylvia Machona Paediatrician WNH-UTH Gertrude Kampekete Chief Newborn officer MOH-HO Chamba Ilunga Paediatrician MOH-MGH Vivian Diliwayo Midwife MOH-MGH Mary K. Bwalya NPO/CAH WHO Muntanga K. Mapani Paediatrician Levy-MOH Kunda Mutesa Kapebwa Neurologist Neonatologist Mary Nambao Liaison Officer GFF Eliana Jimenez Soto Consultant GFF