Series www.thelancet.com Published online May 20, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60582-1 1 Every Newborn 4 Health-systems bottlenecks and strategies to accelerate scale-up in countries Kim E Dickson, Aline Simen-Kapeu, Mary V Kinney, Luis Huicho, Linda Vesel, Eve Lackritz, Joseph de Graft Johnson, Severin von Xylander, Nuzhat Rafique, Mariame Sylla, Charles Mwansambo, Bernadette Daelmans, Joy E Lawn, for The Lancet Every Newborn Study Group Universal coverage of essential interventions would reduce neonatal deaths by an estimated 71%, beneit women and children after the irst month, and reduce stillbirths. However, the packages with the greatest efect (care around birth, care of small and ill newborn babies), have low and inequitable coverage and are the most sensitive markers of health system function. In eight of the 13 countries with the most neonatal deaths (55% worldwide), we undertook a systematic assessment of bottlenecks to essential maternal and newborn health care, involving more than 600 experts. Of 2465 bottlenecks identiied, common constraints were found in all high-burden countries, notably regarding the health workforce, inancing, and service delivery. However, bottlenecks for speciic interventions might difer across similar health systems. For example, the implementation of kangaroo mother care was noted as challenging in the four Asian country workshops, but was regarded as a feasible aspect of preterm care by respondents in the four African countries. If all high-burden countries achieved the neonatal mortality rates of their region’s fastest progressing countries, then the mortality goal of ten per 1000 livebirths by 2035 recommended in this Series and the Every Newborn Action Plan would be exceeded. We therefore examined fast progressing countries to identify strategies to reduce neonatal mortality. We identiied several key factors: (1) workforce planning to increase numbers and upgrade speciic skills for care at birth and of small and ill newborn babies, task sharing, incentives for rural health workers; (2) inancial protection measures, such as expansion of health insurance, conditional cash transfers, and performance-based inancing; and (3) dynamic leadership including innovation and community empowerment. Adapting from the 2005 Lancet Series on neonatal survival and drawing on this Every Newborn Series, we propose a country-led, data-driven process to sharpen national health plans, seize opportunities to address the quality gap for care at birth and care of small and ill newborn babies, and systematically scale up care to reach every mother and newborn baby, particularly the poorest. Introduction Reduction of the neonatal mortality rate (NMR; deaths within the irst 28 days of life), has lagged substantially behind progress in child mortality, with almost 3 million deaths in 2012 being a major uninished agenda at the end of the Millennium Development Goal era. 1,2 Globally, the average annual rate of reduction in neonatal mortality is around half that for children after the irst month of life and half that for maternal deaths, 3 and progress is even slower for the world’s 2·6 million stillbirths. 4 Although some countries have made substantial advances in newborn survival, progress varies between neighbouring countries and within countries. African countries have made the least progress in reducing the risk of neonatal deaths (28%) compared with countries in east Asia (65%). 2 The irst paper in this Series reviews changes and challenges since the irst call to action for newborn survival in 2005. 5 Although striking progress has been made in agenda setting and the generation and use of evidence in policy formulation, there is little investment, limited large-scale implementation, and major gaps in data for both coverage and process. Hence, it might not be surprising that progress in newborn survival has been slower than in the reduction of child mortality. 3 However, we now have much clearer epidemiological evidence describing the size of the problem and the action priorities—where, when, and whom to focus on. The time of greatest risk for both women and babies is around birth. 1 Small babies—either preterm or small for gestational age or both—are especially vulnerable, accounting for more than 80% of neonatal deaths in south Asia and sub-Saharan Africa. 1 Targeting of small babies has been crucial to acceleration of neonatal mortality reduction in high-income and middle-income countries. 6 Additionally, the evidence for efective and afordable interventions is clearer than ever: 5 universal coverage of maternal and newborn care would avert 59% of maternal deaths, 73% of newborn deaths, and 35% of stillbirths 7 as well as provide ongoing beneits throughout the lifecycle. 1 Table 1 shows the most efective intervention packages to save mothers’ lives and address the three main causes of newborn mortality including basic care for neonates at birth. Full scale-up of these intervention packages could substantially reduce deaths due to prematurity (58%), intrapartum-related deaths (79%), and deaths related to infections (84%). 7 Wide and equitable coverage of care is needed to realise a new vision of grand convergence for the richest and poorest countries of the world, 9,10 including achieving the Every Newborn goals for newborn babies and stillbirths. 1 Of the indicators tracked as a follow-on for the Commission for Information and Accountability, 11 only immunisation is higher than 60% coverage. 12 In fact, coverage is the lowest—and the equity gap the highest—for care around Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60582-1 This is the fourth in a Series of five papers about newborn health UNICEF, Programmes Division, New York, NY, USA (K E Dickson MD, A Simen-Kapeu PhD); Saving Newborn Lives, Save the Children, Cape Town, South Africa (M V Kinney MSc, J E Lawn FRCP); Universidad Peruana Cayetano Heredia, Universidad Nacional Mayor de San Marcos and Instituto Nacional de Salud del Niño, Lima, Peru (Prof L Huicho MD); Consultant, New York, NY, USA (L Vesel PhD); Global Alliance for Preventing Prematurity and Stillbirths, Seattle, WA, USA (E Lackritz MD); MCHIP, Washington, DC, USA (J de Graft Johnson DrPH); Maternal, Child and Adolescent Health Department, World Health Organization, Geneva, Switzerland (S von Xylander MD, B Daelmans MD); UNICEF, Regional Office of South Asia, Kathmandu, Nepal (N Rafique MD); UNICEF, West and Central Africa Regional Office, Dakar, Senegal (M Sylla MD); Ministry of Health, Lilongwe, Malawi (C Mwansambo FRCP); and Centre for Maternal Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK (J E Lawn FRCP) Correspondence to: Dr Kim E Dickson, Programmes Division, UNICEF, NY 10017, USA kdickson@unicef.org