Questions/Answers

Sri Lanka has outstanding health indicators, despite being a Low Middle Income country. Yet it couldn’t achieve MDG 4: reducing the Under 5 mortality rate, because 2/3rds of Under 5 deaths were neonatal deaths, despite having a low Neonatal Mortality Rate (NMR) of 5.8. Addressing the NMR, in particular prematurity and LBW contributing to 29.9% of NMR, is then crucial Although 99.7% of deliveries occurred in hospitals, many didn’t have facilities to handle neonatal complications. Such babies were transferred to Lady Ridgeway Hospital (LRH), Colombo, the premier tertiary care Children’s Hospital, but arrived in poor condition, majority battling hypothermia and hypoglycaemia, as no organized neonatal transport system existed in the country. Consultant Neonatologist at LRH having identified the role poor transport played in neonatal morbidity and mortality, initiated the Neonatal Transport Project, a unique initiative led by the Neonatal Team at LRH. Collaboration was initiated between LRH and John Radcliffe Hospital, Oxford to introduce a Neonatal Transport Service (NTS), by developing a scalable, self-sustaining, training and service model of newborn transport for Western Province. The challenge was to provide the service using only existing staff and a modified ambulance. A year after, of those using NTS 88% had normal temperatures on admission, (versus 40% in other group) and none were hypoglycemic. Consequent to this success, Neonatal Team was requested to setup a National NTS by the Ministry of Health. The Team established the Neonatal Transport Forum (NTF) with members from all 9 provinces, won a grant from the World Bank and successfully introduced neonatal transport to the whole country by conducting neonatal transport workshops and using modified existing ambulances. Around 39% of global neonatal deaths occur in the SAARC region. To share knowledge and encourage replication, NTF invited Neonatologists from India, Bangladesh, Nepal and Maldives for the Master Trainers’ workshops.

The overall objective was reducing neonatal mortality and morbidity. Despite increasing the number of NICUs & Neonatologists with regionalization of the NICUs to achieve equity and improve quality, the reduction of NMR was very slow. The neonates at risk, the premature and LBW, the majority of them born in resource poor peripheral hospitals, were transported using ordinary ambulances not equipped to cater for neonates, accompanied by a person/s untrained in the care of a critically ill newborn; often they were transported swaddled in arms of a parent or nurse in private/hired vehicles, with ambu bags for those with respiratory issues. Data at LRH highlighted neonates transferred from resource poor periphery reached LRH in very poor conditions, detrimental for survival. Thus, the Neonatologist at LRH proposed the introduction of a Neonatal Transport Service (NTS) as a strategy for reducing neonatal mortality and morbidity. Until then an organized NTS didn’t exist in the country. The initiative had two specific objectives • Introduction of NTS to reduce hypothermia and hypoglycemia in neonates transported to LRH. • To encourage policy makers and healthcare providers to initiate a national NTS as a strategy to reduce neonatal mortality and morbidity, by demonstrating the success of the NTS.

• Neonatal Transport Service (NTS) was innovative, as no organized NTS existed in Sri Lanka or South Asia. It’s a frugal innovation since costs were limited to modification of ambulances, as it operated with existing staff. • The initiative piloted at LRH, formed the Neonatal Transport Forum (NTF). It coordinated the National NTS for the Ministry of Health covering all nine provinces, thus allowing at risk neonates in remote, resource poor areas access to quality, sophisticated facilities. • Distribution of LBW neonates are skewed towards lower wealth quintiles, hence this intervention is clearly pro-poor. • Free service benefits the poor, previously very challenged in spending on hired transportation. Provision of ‘back transfers’ helps the poor households from economic, social and emotional standpoints. • Evidence based decision making using past data to identify the problems of poor transport was noteworthy. • It’s a model for Partnerships in serving the poor: partnerships among Paediatricians, academics, ministry staff and provincial administrators; and among local and foreign collaborators in training and funding, particularly in involving other SAARC countries, with greater poverty and neonatal mortality risks. • Development of protocols, regular evaluations of neonatal transport beneficiaries and service quality planned for monitoring and developing NNTS are intended to ensure quality and transparency.

SDG Target 3.2 - all countries to reduce neonatal mortality to 12 per 1,000 live births and under-5 mortality to 25 per 1,000 live births by 2030. In 2014 our NMR was 5.6 and U5MR was 9.4 Therefore the SDG target for NMR is 2.2 by 2030 The NMR has been very slow to decline. Hence it was necessary to look at the problem from a different perspective. This initiative addresses the issue by introducing a Neonatal Transport Service to the country. 75.1% of Under 5 deaths are neonatal deaths. The highest proportion, 29.9%, is due to prematurity and LBW. Though highly specialised neonatal facilities are available at the centre, neonates reach the centre in poor condition as the existing modes of transportation from resource poor periphery by standard ambulances/ private vehicles, sometimes by hand, did not address their special needs for protection from hypothermia, hypoglycaemia and stresses related to transportation. NTS also provides safe ‘back transfers’. This enables neonates to be safely moved to hospitals closer to their homes for follow up care. This improves economic, social and emotional wellbeing of families. It also frees cots at tertiary care centers, in high demand for high risk neonates.

Over the past decade despite improving infrastructure, manpower, facilities for ventilation and availability of surfactant, the reduction in NMR had been very slow. The two largest contributors for neonatal deaths are prematurity and LBW, contributing 29.9% of all neonatal deaths. Though state of the art facilities are available in the center, most sick neonates reach the center in very poor condition, leading to a cascade of complications resulting in death. In the event of survival they are liable to develop lifelong disabilities. Studies have shown that when sick preterm and LBW neonates are transported by a skilled Neonatal Transport Service their survival is always better. The reason is an organized and skilled neonatal transport team functions like a mobile NICU. They take the NICU facilities to the referring hospital, establish the service there and stabilize the baby and provide NICU care en route to the centre. The chances of neuro - developmentally intact survival is more in neonates who are transported by this way. Our initiative, the Neonatal Transport Project initiated a skilled organized Neonatal Transport Service to the Western Province. This led to the development of the National Neonatal Transport Service

Data before the Project showed 41.6% arriving in incubators in adult ambulances/ private vehicles; 20.2% transported swaddled in arms of a parent /nurse. It was disturbing to see 64.5% had low temperatures on admission, despite 41.6% arriving in incubators. Project results showed 88% of neonates transported by the Team had normal temperature despite them being more preterm and much smaller. The other group, in spite of being more mature and bigger, had normal temperature only 40%. All neonates transported by the Team had normal blood sugar, whereas 10% of the other group had low blood sugar. When a neonate has to be transported, the general feeling was to dispatch quickly. In the rush, neonates were put into incubators that were not pre-warmed, resulting in cold incubator getting warmed up using the baby’s temperature during the transfer, leaving the baby cold on arrival. Attitudes were changed at the workshops. Trainees highly appreciated the scientific knowledge gained. The Project won the British Medical Journal Awards South Asia 2017 under the category of ‘Healthcare Innovation of the Year’. It received due recognition. Generated much enthusiasm among the participants from the region as a way forward, with all countries aiming to reduce newborn deaths.

For Sri Lanka the SDG target for NMR has been set as 2.2 by 2030. When the NMR is already low achieving further reduction is a daunting task. Over the past decade although deaths due to sepsis, birth asphyxia and meconium aspiration have come down, the decline in NMR has been very slow. This is despite increasing the number of NICUs and Neonatologists with regionalization of the NICUs to achieve equity and improve quality. 75.1% of Under 5 deaths are due to neonatal deaths. The highest proportion, 29.9% are due to prematurity and LBW. This hasn’t been addressed. Though all facilities are available at the centers, most sick neonates, especially the preterm and LBW, arrive in very poor condition leading to a cascade of complications resulting in death or developing lifelong disabilities. To ensure these neonates survive, an organized skilled neonatal transport service was the solution. However no such organized skilled neonatal transport was available in Sri Lanka or in the whole of South Asia. Hence the neonatal transport initiative at LRH was an innovation as well as a way to realize the SDGs in Sri Lanka and in South Asia.

The neonatal transport Project of Lady Ridgeway Hospital for Children (LRH) is an adaptation from the developed countries. The service is widely used in all developed countries to ensure the safety of the neonates and staff during transportation and to minimise the risks and stresses encountered by the neonates during transportation For Sri Lanka it’s an adapted innovation. Collaboration was established between LRH, Colombo and John Radcliffe Hospital, Oxford, UK to advice, train and contribute to the development of a neonatal transport service via a pilot project based at LRH with a potential to roll out across the country. There are no scientific data available in developed countries on neonates who have not been transported by an organized neonatal transport service. The reason for this is in developed countries where scientific research is carried out, have been utilising organized neonatal transport for many years, therefore there is no cohort to study on. On the other hand in South Asia an organized neonatal transport service is non-existent. But no scientific data is available as facilities for research is limited. Hence the Project is an adapted innovation and has also produced a set of valuable scientific data.

In 2013, Consultant Neonatologist at the Lady Ridgeway Hospital (LRH) invited a friend, a Consultant Neonatologists from John Radcliffe Hospital (JRH) Oxford, UK to help organize a neonatal transport project at LRH. He arrived with a team from JRH on voluntary basis offering their services free of charge. Team comprised Neonatal Transport Lead, another Consultant Neonatologists and a Specialist Neonatal Nurse Practitioner from JRH. The cost of economy class airfare and accommodation were borne by WHO and UNICEF. The Ministry of Health and Perinatal Society supported the workshops. Team spent five days. Prior to arrival, Team had discussions over Skype and email to agree a clear set of objectives. It was decided to have the NICU at LRH as the Receiving Center providing the transport service to the Western Province. Transport Team was formed from the existing NICU Staff. Ordinary ambulance from hospital pool was modified at minimal cost. Four doctors and eight nurses selected from the NICU were given extensive training. Named ambulance driver was specially trained. Another 84 doctors and nurses selected from NICUs in the Western Province were trained in essential skills related to newborn transport. The Project was carried over a period of one year.

Yes

The recognition and the commendation the Project gained from the paediatric fraternity and the policy makers at 2014 academic sessions of the College of Paediatricians and the Perinatal Society was the stepping - stone for the national roll out. It was a frugal innovation, as it did not impose heavy resource demands on the Ministry, hence was easily translated across the country. The cohort of Master Trainers, trained by the Oxford Team, carried out the training throughout the country. Since May 2013 to September 2017 the Oxford Team and the Local Trainers have trained 747 personnel including Paediatricians, junior doctors and nurses throughout the country. They in turn provide ‘In house training’ to their staff in their own neonatal units. The neonatal transport manual that was prepared facilitated the transferability of knowledge and techniques across the country. Inclusion of participants from SAARC countries created the potential for transfer of expertise on neonatal transportation to those countries with higher NMR. Concept paper submitted to SAARC Secretariat. The publicity and recognition the Project received by winning the BMJ Awards South Asia 2017 will have a positive impact in the region as a way forward to reduce the very high NMR.

The LRH Project used a model that could be termed a ‘frugal innovation’ as the Neonatal Transport Service (NTS) was set up, involving the use of trained neonatal staff from the NICU and utilizing a modified ambulance. This meant that the project was kept low cost, and this strongly ensures future sustainability. The success of the NTS Project at LRH led to the Neonatal Team being requested to set up a National Neonatal Transport Service within the Ministry of Health The Neonatal Transport Forum (NTF) was set up with representations from all nine provinces to expand the NTS to the provinces. It secured a World Bank Grant following competitive bidding under the Innovative Projects of the Ministry of Health. Funds were available for training and for modifications of ambulances. Since May 2013 to September 2017 the Oxford Team and the Local Trainers have trained 747 personnel including consultants, medical officers and nurses throughout the country. The use of existing staff to carry out neonatal transportation is one of the strongest aspects with regard to sustainability. The training of trainers regionally is another aspect, as it ensures that the staff needed can be trained in the province itself. Oxford Team with inputs from the local trainers compiled a comprehensive Neonatal Transport Manual to facilitate the training and to maintain standards. Harnessing local expertise in the development of the manual is also an important feature from a sustainability perspective. The cost was borne by the World Bank, A copy is given free of charge to all the participants at the workshops. With time demand for the service will grow, especially from parents who want the best care for their neonates. This will also ensure the sustainability of the service, as the policy makers would be pressed to continue with the service.

The National Neonatal Transport Service (NTS) was set up under the Ministry of Health and its long term sustainability is assured by including its operation within the National Health policy of the country. Carrying out training at provincial level, and the creation of regional NICUs ensures the support of the Provincial administration in this process, The Director General of Health Services (DGHS) appointed a Technical advisory Committee on the national roll out of the Neonatal Transport Service chaired by a Deputy DGHS. Members are Director of Transport, Director of Nursing, Director of LRH, representatives from the Family Health Bureau, Sri Lanka College of Paediatricians, Perinatal Society of Sri Lanka and the Neonatal Transport Forum. This committee meets once in two months to discuss progress. Family Health Bureau is the focal point for newborn and child health. It has developed a Newborn Action Plan, which has included Neonatal Transport Services as a strategy for reducing NMR to achieve SDGs. The Technical Advisory Committee on Newborn and Child Health comprises all stakeholders involved in newborn and childcare. The committee regularly evaluates and monitors progress of the Neonatal Transport Service. The professional associations, the Sri Lanka College of Paediatricians and the Perinatal Society of Sri Lanka function as monitors as their members were actively involved with the initiation of the Project. The activities are discussed at their Council meetings on regular basis. Examination, Training & Research Unit of the Ministry of Health is funding the training workshops in all 9 provinces. This is also monitoring the progress. The National Quality Secretariat under the Ministry of Heath now collects data on two neonatal indicators, Temperature and blood sugar on admission to a Neonatal unit. Neonatal Transport Forum has organized regular audit meetings at provincial level and soon will have a national level meeting.

Yes

Scientific Evaluation: The initial project was carried out over a period of one year, 26.6.2013 – 25.6.2014 by the Neonatal Team at LRH. Temperature and blood sugar were recorded on admission. 60 neonates transported by the Team were compared against 60 not transported, admitted sequentially to the same Unit. 88% neonates transported by the Team had normal temperature (despite them being more sick, preterm & LBW) compared to 40% in the latter group (in spite of them being more mature and bigger). All transported neonates had normal blood sugar but 10% of neonates not transported had low blood sugar. Peer Evaluation: Findings presented at 2014 Annual Scientific Congresses of College of Paediatricians and Perinatal Society. Results were highly acclaimed and proposed a national roll out. Both societies are stakeholders in the process and evaluate progress at Council meetings. Administrative Evaluation: Conducted by Technical Advisory Committee on Newborn and Child Health, Family Health Bureau, Ministry of Health advised a national roll out. Health Ministry appointed a technical committee with all stakeholders to evaluate and monitor progress. Recognition: This won the ‘Healthcare Innovation of the Year’ award, British Medical Journal Awards South Asia 2017, competing against 2015 projects.

Following recommendations of Technical Advisory Committee on Newborn and Child Health, the Ministry of Health incorporated Neonatal Transport as a National Service and approved the national roll out. The Neonatal Transport Forum (NTF) was formed in 2015 with representation from all 9 provinces to facilitate transport networks and training workshops, to standardize equipment, to ratify protocols and guidelines, to set out clinical governance guidance and systems of audits. NTF secured funding from the World Bank under Innovative Projects to establish a national Neonatal Transport Network in Sri Lanka. Master Trainers trained by the Oxford Team conducted transport workshops in all provinces for the staff working in the regional NICUs. A manual on Neonatal Transport was prepared by Oxford Team and NTF. Success of the Project, the first such exercise in South Asia, was shared with other South Asian countries through ‘South2South Collaborative for Health’, an initiative of UNICEF Regional Office. Neonatologists from India, Bangladesh, Nepal and Maldives participated at the workshops. To encourage introduction of Neonatal Transport to help achieve SDGs, in SA with 39% of world neonatal deaths and very high NMR, a concept paper on Neonatal Transport was forwarded through Sri Lankan Government to the SAARC Secretariat.

The temperature and blood sugar levels of all neonates were recorded on admission to the Neonatal Unit. The recordings of 60 neonates served by the Neonatal Transport Service were compared against that of 60 other neonates admitted sequentially during this period. All neonates admitted to the Neonatal Unit at the Lady Ridgeway hospital are transferred from other hospitals (out born) as it is the tertiary care hospital for children. The data was analyzed after one year by the Oxford team together with the Neonatal team at the Lady Ridgeway Hospital. The choice of these two indicators, for assessing the success of the Neonatal Transport Service lay in how crucial normal temperatures and blood sugar are for the survival of neonates, and their importance in neonatal morbidity and neural development of the infants. These intrinsic indicators were considered to be proxy for neonatal survival and survival outcomes. The Neonatal Transport Forum developed two sets of indicators, temperature and blood sugar on admission to the Neonatal Units, to be adopted nationwide under the purview of the National Quality Secretariat. These will measure the characteristics of the neonates transferred and their survival outcomes and also the efficiency and the compliance of the service.

• Consultant Neonatologist, LRH formed collaboration between LRH and John Radcliff Hospital, Oxford, to introduce and develop a neonatal transport service for LRH covering Western Province. • Oxford team introduced neonatal transport to 84 local health professionals: Neonatologists and Paediatricians, medical and nursing officers working in NICUs from all 9 provinces. • A core group, four medical and eight nursing officers from LRH Neonatal team was trained in depth on safe newborn transfers. This Team implemented the NTS using existing equipment. An ambulance was modified for safe neonatal transfers. • Officials from the Ministry of Health were very supportive from the pilot stage onwards and provided funds to modify the ambulance for neonatal transportation. • Ministry officials responded positively on seeing the scientific evidence from LRH to approve a national roll out of Neonatal transportation • LRH Team involved neonatal staff in all 9 provinces and formed Neonatal Transport Forum (NTF). In just over two years NTF has successfully introduced neonatal transport to the whole country including the North and East. • NTF got the National Quality Secretariat to adopt the selected indicators to measure outcomes. • Contribution from International funding agencies. NTF secured a grant under Innovative Projects (Health Sector Development Project) funded by World Bank for procurement of equipment for 15 regional Neonatal Transport Centers and modification of existing ambulances in 9 provinces. • NTF trained Neonatologists from India, Bangladesh, Nepal and Maldives through the 'South 2 South Collaborative for Health’ initiative of UNICEF. • A concept paper formulated by NTF to introduce neonatal transport in SAARC countries was submitted to the SARRC Secretariat. • The main beneficiaries of this project are the neonates and their families, with their increased chances of survival, better survival outcomes and the economic support of free transportation that averts ruinous health expenditure.

It is very encouraging and satisfying when a small initiative started at one neonatal unit transforms into a national service. Three key lessons were learned. Firstly a scientific approach is very important, both in identifying necessary interventions and in ensuring that effective interventions are expanded. NTF has built in evaluation processes as NTS is operationalized island-wide. Improving systematic recording of admission data, follow up of patients, and research must be undertaken targeting NMR reduction and the achievement of the health SDG. Secondly the important role played by partnerships was realized during the project. Effective interactions between the Ministry of Health, Neonatal care providers, administrators, academia (local and foreign) and international agency officials allowed first the LRH Neonatal team, and later the NTF to achieve their vision and benefit large numbers of neonates and their families. Lastly, the lesson learned related to human resource management. Chronic shortage of nurses and administrative practices of transferring nurses irrespective of their special training were constraints faced during this process. At a personal level, many nurses were reluctant to take on new responsibilities preferring to remain within their comfort zones. The importance of motivating staff and initiating administrative changes at national level were recognized.