Digital solutions to eradicate newborn mortality in low-income countries

Problem In Sub-Saharan Africa – the region with the highest under-5 mortality rate in the world – a child is 10 times more likely to die in their first month of life, than if they were born in a high-income country in Europe or North America. Despite huge strides in reducing global child mortality, ~2.3m babies will die in their first month of life – 90% of them will be in Africa and Asia. Two thirds could be saved – some 1.2m babies – not through expensive drugs or medical equipment – but by getting the basics of newborn care right and ensuring adherence to existing evidence-based guidelines. Unless we can ensure a universal, basic standard of care for every one of these babies, one where common conditions, like sepsis, jaundice, and hypothermia are quickly spotted and handled, this “silent emergency” will continue to claim the lives of too many babies and leave others with lifelong disabilities. Despite many births now occurring in health facilities, many countries are not on track to meet the UN Sustainable Development Goal of reducing neonatal mortality to fewer than 12 per 1000 live births by 2030, and in Zimbabwe, neonatal mortality rates have increased from 29 to 32 deaths per 1,000 live births in the last 2 years. Economic challenges – compounded by climate change and health related shocks, like cholera and COVID-19 – have contributed to a rapid deterioration in health outcomes across 163 maternal, new-born, child and adolescent health indicators. The cost of inaction is immense, with preventable newborn deaths devastating mothers and families and wreaking havoc on poverty-stricken nations, with the GDP loss in Africa estimated at $50k per child death. Lack of context-specific clinical guidelines, training and education remain key barriers to improving care and lowering neonatal mortality. However, it is hard to create African guidelines or education materials without local, accurate data. Routine electronic health data systems are vital, yet rare in low-resource settings. Where they do exist, they tend to be disease-specific (e.g. for HIV). Efforts to improve newborn care, such as standalone educational programs and paper-based guidelines, show limited success. In high-resource settings, digital decision support tools are increasingly used to enhance care, but in low-resource areas, these tools are still in development and lack integration into routine care.

“Neotree has the life-saving power of a drug…it’s a long-term resource – an investment in better care today and in the future”. Dr Simbarashe Chimhuya, Neotree Principal Investigator, Zimbabwe and Clinical Lead at Harare Central Hospital and a lecturer at Zimbabwe University

Overview Neotree exists to eradicate preventable newborn mortality. Neotree’s use of low-cost, open-source technology has potential to improve care and transform the life chances of millions of babies and their families in poor and underprivileged communities across Africa and beyond. Promising collaborations are underway with Ministries of Health (MoH), the UK Foreign, Commonwealth and Development Office (FCDO) and UNICEF in Zimbabwe and Malawi. And the co-Chair of the African Neonatal Association (ANA) has said he “would like to see Neotree everywhere”. But as an early-stage non-profit, Neotree does not yet have the necessary capital, capacity, and infrastructure to best capitalise on its successful research, innovation, and relationships. Collaboration is key to its mission. Having already enabled ~35,000 babies to be better cared for by ~1,000 healthcare workers since 2018, Neotree is looking to expand its network of partners to support rollout into more hospitals and primary health clinics (PHC) in Zimbabwe and Malawi so that it can maximise impact in saving babies and improving the quality of newborn care.

Solution Sometimes radical advances can be achieved with simple solutions. Neotree has designed a digital system that puts the lifesaving power of technology into the hands of healthcare workers. 

Co-designed with local clinicians and digital specialists, Neotree’s innovative technology provides a low-cost, locally owned and locally adaptable solution to deliver standard, evidence-based care to every baby, across a full range of newborn disorders. Neotree’s platform offers the only open-source, digital quality improvement system that combines: (i) real-time data collection, (ii) clinical decision support (that links to labs for rapid test results) and (iii) in-built low-dose, high-frequency training and education, empowering clinicians to better care for vulnerable small, newborns at the bedside and save lives. Neotree guides healthcare workers to: (i) perform the right tests, at the right time, (ii) capture real-time data as part of routine care, (iii) more quickly spot and treat deadly conditions (e.g. sepsis), (iv) assess aggregate data and work with governments to improve outcomes locally and nationally and (v) provide clinical teams with data for quality improvement activities. Decision support is delivered based on the latest available evidence and national and international clinical guidelines. Neotree is also exploring the use of AI and machine learning to optimise predictive clinical algorithms to empower healthcare workers to deliver the best and most timely care possible.

Over the last 2 years Neotree has already achieved:

• • Better care for 35,000+ babies, by 1,000+ healthcare workers in 4 hospitals (2 in Zimbabwe, 2 in Malawi) and 1 primary health clinic, with early data demonstrating the app is low-cost, time-efficient and improves newborn care, with:
    • 50% fewer babies weighing 1.5-2.5kg dying in Chinhoyi Provincial hospital, Zimbabwe.
    • 97% reduction in previously overprescribed oral antibiotics on discharge (from 99% to 2%) at Sally Mugabe Central Hospital, Zimbabwe.
    • 70% reduction in hypothermia rates at Kamuzu Central Hospital, Malawi.
    • Faster blood culture results (from 5 days to under 48 hours), improving antimicrobial stewardship and infection control.
    • Improved confidence in clinical decision making, clinical skills, critical thinking, and standardisation of care as reported by healthcare workers.
  • Close working relationships with target Ministries of Health. Neotree:
    • Is Ministry of Health approved for electronic admission and discharge of newborns at project sites – digitising previous paper-based systems

They also have completed a proof-of-concept integration with Malawi’s District Health Information System (DHISv2) and have piloted  an integration with the national Electronic Health Record system in preparation for nationwide rollout in 1,500+ sites in Zimbabwe.

Sustainability The Neotree digital system has strong in-country buy-in and is easy for local teams to adopt and use. So much so that with little need for external support, the use of Neotree in Zimbabwe increased during Covid when travel to the country was limited. From the outset, the use of Neotree’s low-cost, open-source software has provided a pathway to a highly scalable, locally driven, and sustainable solution. Rather than have local health facilities and MoH locked into costly commercial agreements with private IT firms, their teams are free to configure and own the software and data locally, and to create and benefit from a community of developers and clinicians who can support ongoing adaptations and software development.

Neotree now has cost and time motion data that offer strong evidence that Neotree is both cost and time efficient at improving newborn care in hospitals. This will need to be evaluated at scale for Primary Health Care settings.

1. Cost per baby at scale: A health economics evaluation conducted during the Wellcome trust funded pilot implementation study across 3 hospitals (2 in Zimbabwe and 1 in Malawi) used activity-based costing and expenditure approaches from a provider perspective to estimate the cost of developing and implementing Neotree (manuscript in preparation). Data were collected through expenditure reports, monthly staff time-use surveys and interviews with the project staff. Average monthly cost per admitted child varied between US$13 and $53. Cost differences were driven by the number of babies admitted. Under routine conditions and at scale, total implementation costs are estimated to reduce substantially, up to 65%, reducing cost per admitted child to as low as $5. Neotree is also just commencing a short pilot with UNICEF-Zimbabwe (funded through the Health Resilience Fund) to run a more detailed health economics modeling of existing costing data to estimate cost per life saved and cost at scale.
2. Time efficiency: At the same time, a pilot time-motion survey was conducted in Malawi, at KCH, and a comparable hospital (Bwaila District Hospital) where Neotree was not implemented. Median time to admit a baby was 26 mins (IQR 21,30; n=250) using Neotree and 27 mins (20,40; n=34) using paper-based systems and to discharge a baby was 9 mins (7,13; n=246) using Neotree and 3 mins (2,4, n=50) using paper-based systems.

Neotree adds value to other available solutions in that it is committed to improving newborn care and ending preventable newborn deaths by working with (not competing against) existing health solutions and enabling clinicians to provide better care for small vulnerable newborns with the resources they have.

Unlike many other disease-specific, standalone interventions, the Neotree platform is a horizontal intervention which works across all newborn disorders, which means Neotree is able to add value to a great many new and existing digital health solutions in low-income settings. (Neotree has algorithms for: resuscitation, thermoregulation, convulsions, low birth weight, prematurity, hypoglycemia, HIV, respiratory distress, neonatal encephalopathy, sepsis, syphilis, jaundice and congenital abnormalities).

Given the whole premise of Neotree is collaboration – all data is open-source, designed to maximise interoperability, and is free for others to download and use, which Neotree will further support by developing how-to guides to make adoption and implementation easier.

Neotree is innovating for immediate impact, and is collaborating with Ministries of Health to integrate the system with national databases to ensure long-term sustainability. Ministries of Health across Africa are enthusiastic about building digital health systems using open-source technology that they can own and customise to their specific needs. As Neotree’s platform is open-source, interoperable and runs on low-cost hardware, Neotree’s long-term strategy is that Ministries of Health in multiple countries implement Neotree’s technology because the cost of implementation/ownership is as low as possible and countries that adopt it have complete ownership of both the technology and the resulting data (e.g. on Ministry of Health servers in-country). As an open-source solution, Ministries of Health would be able to “self-serve” access to Neotree technology and eventually adopt it directly themselves.

In Malawi, with UK FCDO funding, and support from UNICEF-Malawi, the Global Health Informatics Institute and Malawi’s Ministry of Health, Neotree has adapted and is now piloting its platform for Primary Healthcare. Preliminary testing indicated high-levels of usability and ease of use of adapted scripts, and qualitative data suggest Neotree has strong potential to be both acceptable and feasible in Primary Care.

Neotree technology has also been piloted for integration with the national Electronic Health Record system in preparation for nationwide roll out in Zimbabwe and with the most common aggregate data system for healthcare in Sub Saharan Africa: the DHISv2.

Neotree enables a straightforward modern workflow for neonatal care: seamlessly integrating real-time data capture, educational resources, clinical decision support, and visual data dashboards; feeding information into existing systems like the DHIS2. Its clinical decision support algorithms are accessible via an editor platform that can be updated and adapted according to local requirements and to optimise use of the new technology by less tech savvy users. By embedding Neotree’s use on admission for all babies and adhering to national and international care standards, Neotree adds value by ensuring evidence-based universal care.

Neotree is exploring all potential avenues for collaboration to scale Neotree and use of its technology to maximise impact in saving lives, improve neonatal care and strengthen health systems. Beyond working with target governments, Neotree is seeking funding to partner with other non-governmental actors to strengthen and/or expand their own maternal health/neonatal platforms, by advising and inputting into their Neonatal modules and guidelines, and/or improving their databases and workflow processes. For example, by automising and enabling real-time data collection, Neotree technology can help existing platforms to improve speed, accuracy and quality of care (since many existing solutions use retrospective, paper-based, data entry systems that are inefficient, costly, and prone to errors).

By working with others to enhance neonatal care and improve data collection, Neotree is breaking down silos and building a robust network through which global learning and innovation can flourish; one that unites researchers, doctors, families, communities, and NGOs, who in the past operated separately.