645 Costs of developing and implementing a digital quality improvement tool, Neotree, designed to improve newborn survival in Malawi and Zimbabwe

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Objectives Ensuring existing low-cost evidence-based interventions are implemented for all sick and small newborns could avoid around two-thirds of the 2.4 million newborn deaths within the first 28 days of life [1]. Neotree, an open-source digital quality improvement tool combining data capture with education and clinical decision support is a solution to this implementation gap and is a highly acceptable, feasible, and usable tool, resulting in perceived and observed improvements in newborn care [2–6]. As part of a pilot implementation evaluation study [7], these study objectives are to estimate the costs of developing and implementing Neotree and to explore the impact of Neotree implementation on time spent on procedures and activities in the delivery of care. Methods Activity-based costing and expenditure approaches were used to estimate the cost of developing and implementing Neotree in three sites; Kamuzu Central Hospital (KCH) in Malawi, and Sally Mugabe Central Hospital (SMCH) and Chinhoyi Provincial Hospital (CPH) in Zimbabwe. Costs were estimated from a provider perspective for one year. Data were collected through expenditure reports, monthly staff time-use surveys, and interviews with the project staff. Sensitivity and scenario analyses were conducted. A pilot time-motion survey was conducted at KCH and a comparable hospital (Bwaila District Hospital, Malawi) where Neotree was not implemented. Results Total cost of pilot implementation of Neotree was US$35,288 (KCH), US$48,086 (SMCH) and US$38,308 (CPH; Table 1). Average monthly cost per admitted child was US$14 (KCH), US$13 (SMCH) and US$53 (CPH). Neotree staff were the main cost component with 68% of total routine costs (range 57% to 74%; Figure 1). Under routine conditions and at scale (in other words without development activities, with Neotree implemented by Ministry of health instead of NGO), total implementation costs are estimated to reduce substantially, up to 65% reducing cost per admitted child to as low as $5 (KCH), $6 (SMCH) and $17 (CPH). Admission times were similar using Neotree against paper-based systems (median admission time 27 minutes compared to 26 minutes). Discharge times were somewhat longer (median discharge time 9 minutes compared to 3 minutes). Conclusion A digital quality improvement tool with potential to improve newborn care and survival is low-cost and time efficient. The number of admitted babies per month impacts implementation costs. Large scale implementation, with the ability to capacitate local staff, would have a significant reduction on implementation costs. Implementation cost at scale may be even lower due to economies of scale. References Lancet Bhutta ZA, et al 2014 Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Learning Health Systems Heys M, et al 2022 Development and implementation experience of a learning healthcare system for facility based newborn care in low resource settings: The Neotree. Frontiers in Public Health Crehan C, et al. 2022 Usability-Focused Development and Usage of NeoTree-Beta, an App for Newborn Care in a Low-Resource Neonatal Unit, Malawi. BMJ Open Qual Gannon H, et al. 2021 Electronic application to improve management of infections in low-income neonatal units: pilot implementation of the NeoTree beta app in a public sector hospital in Zimbabwe. BMJ Glob Health Crehan C, et al. 2019 The NeoTree application: developing an integrated mHealth solution to improve quality of newborn care and survival in a district hospital in Malawi. Wilson E, et al. BMJ Open 2022 Protocol for an intervention development and pilot implementation evaluation study of an e-health solution to improve newborn care quality and survival in two low-resource settings, Malawi and Zimbabwe: Neotree.

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