Monitoring the implementation and scale-up of a life-saving intervention for preterm and small babies: Facility-based Kangaroo Mother Care

Background Kangaroo mother care (KMC) is an evidence-based intervention with large protective effects on neonatal mortality and morbidity, especially among small babies. Despite the available evidence, KMC adoption, implementation and scale-up has lagged. The purpose of this paper is to inform current and future KMC implementation by identifying achievements and challenges in countries that are in the process of scaling up KMC. Methods We collected and analyzed information to track the status of facility-based KMC in countries identified by the KMC Acceleration Partnership. We assessed the status of the scale-up in six priority countries (Ethiopia, Malawi, Nigeria and Rwanda in Africa, and Bangladesh and India in Asia) for three periods: 2014 and prior, 2015-2017 and 2017-2019 across six strategic areas: national policy, country implementation, research, knowledge management, monitoring and evaluation and advocacy. We collected information through in-depth interviews with key participants, quantitative data extraction from the Demographic Health Survey and secondary data extraction from policies, briefs, program reports and other documents. Results Progress in terms of national policy and advocacy appeared to occur quite quickly and evenly across the six priority countries, despite being at different stages during the first assessment. In the areas of country implementation support and research, progress occurred more slowly and results were more variable across countries. It was noted that the number of health facilities offering KMC services increased in all six priority countries, but coverage of KMC was difficult to estimate, demonstrating the ongoing challenges in the area of monitoring and evaluation despite progress made in integrating KMC indicators into national health information systems in five countries. Among the six priority countries – Malawi and Bangladesh had fully achieved at least four the first time six conditions were introduced. Conclusions We documented notable achievements in the dimensions of policy and country implementation across the six countries, which were likely driven by government engagement to prioritize newborn care services and the promotion of KMC as a core intervention for small babies. We noted challenges in critical areas such as ambulatory KMC, follow-up, and monitoring and evaluation. Addressing these gaps while securing funding to allocate human resources adequately, promoting acceptance of KMC for demand creation and facilitating the use of data for decision making will be vital to ensure effective coverage at scale.


1a.
Is there a national policy that includes facility-based KMC as a standard of care for preterm and/or low birth weight (LBW) infants?
1b. If yes, when was it last updated? 1c.
Indicate the names of each policy that includes KMC as a standard of care. Would it be possible to send a copy of the policy or let us know where it is available online? 1d.
What are some of the gaps in these policies for KMC service provision? Is anything being done now or planned to address the gaps? 4f.
To the best of your knowledge, what percentage of preterm/LBW newborns are initiated in facility-based KMC? 1) < 10%.
Level of KMC Implementation/KAP Metrics Percentage of target countries in which (1) KMC activity is limited to one center in the country, (2) KMC has spread beyond one center to a few peripheral centers in the country, (3) KMC is being implemented in a large number of public/government hospitals in the country, and (4) KMC is being implemented in the vast majority of or all public/government hospitals in the country 4) 50-<7 5%. 5) 75% or more. 6) Don't know.
4g. How did you arrive at that estimate (probe on sources of data)?

Goal KAP Metrics
Percentage of target countries with estimated coverage of 50% or higher of all newborns initiated in immediate skin-to-skin contact (interim indicator and proxy for skin-to-skin contact becoming routine care; can disaggregate by birth weight categories where sample size allows) 4h.
To the best of your knowledge, how routine is the practice of placing babies in skin-to-skin contact with the mother right after birth? 1) Very routine -practiced for all babies in all public and private facilities at all levels. 2) Routine practice in public facilities, but variable in private facilities. 3) Not routine practice in either public or private facilities.

4i.
To the best of your knowledge, what percentage of all newborns are initiated in immediate skin-to-skin contact after delivery? 1) < 10%.

Funding KAP Metrics Questions
Funding KAP Metrics Percentage of countries with (1) no funding available, (2) only donor funding available, (3) combination of donor/MOH funding, and (4) no need for donor funds, fully funded by government/MOH (funds have been allocated and released) 5a.
Would you say that funding for KMC is (Please select from the following)? 1) There is no funding available.
2) There is only donor funding available.
3) There is a combination of donor/MOH funding. 4) There is no need for donor funds because KMC is fully funded by the government/MOH. 5b.
What do you think are the most important funding gaps for KMC/care of small babies and what is being done or could be done to fill the gaps?  Is there a national policy that includes facility-based KMC as a standard of care for preterm and/or LBW infants?

Monitoring & Evaluation KAP Metrics Questions
Percentage of target countries in which national policy includes KMC as standard of care 1b. If yes, when it was last updated? 1c.
Indicate the names of each policy that includes KMC as a standard of care. Would it be possible to send a copy of the policy or let us know where it is available online?
For those countries that scored 4 in 2014 we may want to reference that but get specific information (question1c) and ask if they could send it to us -as the 2014 questions combined both policy and guidelines, so it was a bit unclear. 1d.
What are some of the gaps in these policies for KMC service provision? Is anything being done now or planned to address the gaps? 1di.
What have been some of the advances in the past two years on the scale-up of KMC?

Policy KAP Metrics 2a.
Are there national guidelines in place about the care of preterm and LBW infants that include inpatient KMC? 2b.
If yes, when were those last updated?
Percentage of target countries with national guidelines or standards on care of preterm and low birth weight infants (aligned with WHO guidelines to include KMC) In your opinion, are they aligned with WHO 2015 guidelines on care of preterm and LBW infants?
Would it be possible to send a copy of the guidelines or let us know where it is available online? To the best of your knowledge, how routine is the practice of placing babies in skin-to-skin position with the mother right after birth: 1) Very routine -practiced for all babies in all public and private facilities at all levels 2) Routine practice in public facilities, but variable in private facilities 3) Not routine practice in either public or private facilities 4i.

Funding KAP Metrics Questions
Funding KAP Metrics 5a.
Would you say that funding for KMC is (Please select from the following): 1) There is no funding available 2) There is only donor funding available 3) There is a combination of donor/MOH funding 4) There is no need for donor funds because KMC is fully funded by the government/MOH.    LESSONS LEARNED  Government commitment and a positive policy environment is crucial for the acceleration and sustainability of KMC services. The commitment of the MOHFW, which started in 2013, has resulted in achievements such as the development of KMC guidelines, manuals, monitoring tools and the integration of KMC into the NNHP.  The joint efforts of members of the National Technical Working Committee for Newborn Health led to the decision and commitment to scale up KMC in Bangladesh.  The identification of champions at the national level has accelerated the progress of KMC activities in Bangladesh, from the establishment of KMC facilities to participating in committees to scale up KMC.  The engagement of partners supporting the DGHS and DGFP in the capacity-building of service providers and facility readiness has proved essential for the acceleration of KMC.  Motivation and ownership of KMC from managers and providers has been crucial to ensure that KMC services are sustainable.

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FUTURE ACTIONS  Disseminate the findings of the Saving Newborn Lives program in the Kushtia district.  Identify local-level champions who will motivate and mentor new champions.  Develop and implement of a tracking system for KMC services.  Establish KMC learning platform among MOHFW, professionals, donors, United Nations, development partners, and nongovernmental organizations.

KANGAROO MOTHER CARE IN NIGERIA
OVERVIEW In Nigeria, KMC as a method for caring for small babies has been systematically reintroduced through the US Agency for International Development's ACCESS program in 2007. Since then, there have been efforts to integrate KMC as part of the standards for newborn care. The commitment of the Federal Ministry of Health (FMOH) to increase KMC coverage has been noticeable. In 2008, with the help of partners, the FMOH adapted a KMC Training Manual, and in 2013, it included two KMC indicators in the health management information system. The FMOH launched the Nigeria Every Newborn Action Plan, which included KMC as part of the essential care for preterm/low birth weight (LBW) babies in 2016. Most recently, the FMOH included KMC in the Reproductive, Maternal, Newborn, Child, Adolescent Health Plus Nutrition Agenda 2017-2030 1 and in the National Strategic Health Development Plan II 2018 -2022. 2 Also, with partners' support, the FMOH finalised the guidelines for KMC.
The FMOH has been committed to situating facility-based KMC services within the wider context of newborn health. As KMC is included in health policies, there is a need for behaviour change campaigns, displays of KMC posters in healthcare facilities and awareness activities to engage healthcare providers and mothers. There is also a need for data quality improvement, data use and dissemination of findings, which could help to make KMC a widely practiced strategy in Nigeria. approach to reduce mortality among preterm/LBW babies. 6 The analysis also called attention to the need for a national KMC policy and a routine data collection system.

Skin-to-Skin Contact Indicator Percentage
Percentage Percentage of births that had skin-to-skin contact for the most recent live birth in the 3 years preceding the survey N/A 12.0 CHALLENGES  One of the major challenges to accelerate the uptake of KMC in Nigeria is that many health providers are not aware of policies and guidelines that include KMC.  There are funding needs for the training of community health workers, the designation of KMC spaces in health facilities, and dissemination of KMC information through media outlets.  While hospitals collect information about KMC services, the collected data are not used. There is need to use KMC data for decision-making and for finding a more formal way to disseminate lessons learned.  As in most countries, there is a need to strengthen the ambulatory follow-up of small babies.

LESSONS LEARNED
 Collaboration among the FMOH, partners and local champions for KMC has been important for integrating KMC into national policies.  The formation of a neonatal subcommittee has been critical to the acceleration of KMC.

FUTURE ACTIONS
 Ensure harmonisation of KMC indicators and inclusion of the indicators in DHIS2.  Advocate for free maternal and child health services to increase access nationally.  Scale up the national health insurance program to include mothers in the states and communities.  3 The KMC target in these policies was set to reach 80% of preterm babies with KMC by the year 2020. Despite the emphasis that the government has put on reducing neonatal mortality by using evidence-based strategies, such as KMC, the number of preterm/low birth weight (LBW) newborns initiated in KMC remains low.    Make sure KMC is adequately included during the revision process of maternal and child health training materials, such as those on basic and comprehensive emergency obstetric and newborn care, integrated management of newborn and childhood illnesses, and integrated community case management.  Synthesise and use KMC data from the newly added health management information system data.

Utilization of Utilization of Kangaroo Mother Care (KMC) and Influencing Factors Among Mothers and Care Takers of Preterm/Low Birth Weight Babies in Yirgalem Town, Southern, Ethiopia
http://diversityhealthcare.imedpub.com/utilization-of-utilization-of-kangaroo-mother-carekmc-and-influencing-factors-among-mothers-and-care-takers-of-pretermlow-birth-w.pdf As more health facilities are expected to provide KMC services, data collection will be critical to monitor quality, identify gaps, and track services. Engagement of healthcare providers and the identification of champions will help to foster the ownership of KMC as an effective intervention, speeding up the rate at which KMC services are adopted throughout the country. training modules and reporting tools. This work is in progress.
 Currently, all states and UTs report on the status of KMC activities online.

Percentage of LBW newborns initiated in facility-based KMC
There is no mechanism to collect data on KMC parameters at present. Data were submitted to the GOI by 18 states, which revealed that KMC was provided to 0-20% of SNCU-admitted babies in 12 states and more than 20% of SNCUadmitted babies in six states.
 In 2019, it was estimated that 10-< 25% of preterm and/or LBW babies are initiated in facility-based KMC, as per the SNCU online system.  Champions have been strongly advocating through conferences and publications and by conducting nationwide KMC trainings.

Table 2. National Family Survey (NFHS) proxy indicators for kangaroo mother care DHS Indicators Related to KMC (NFHS-4) 2015-16 11 Identification of LBW Babies Characteristic Percentage
Percentage distribution of all live births in the 5 years preceding the survey by mother's estimate of baby's size at birth, according to background characteristics LESSONS LEARNED  The active role of the MOHFW has been critical in India: It designated two working groups to help to accelerate the scale-up of KMC services. One of these working groups is drafting KMC indicators that will be included in the health management information system.  Effective data use for KMC is important for engaging health professionals in KMC programs.

FUTURE ACTIONS
 The GOI established a technical advisory group comprising two working groups that will develop capacity-building, monitoring and evaluation tools for KMC.  Funding has been allocated for KMC, but more SNCUs will designate space for KMC and provide KMC services.  The regional and state newborn resource centers will guide states in implementing KMC and maintaining its quality.

OVERVIEW
Malawi's implementation of kangaroo mother care (KMC) has progressed since its introduction as a pilot in 1999. The Ministry of Health (MOH), with the support of partner organizations, instituted policies and strategies that prioritized the care of small and preterm newborns. National guidelines for KMC were developed in 2005, 1 and in 2015 the MOH launched the country's Every Newborn Action Plan (ENAP), which set an ambitious goal of reaching 75% of eligible newborns with KMC by 2020 and 90% by 2035. 2 Facility-based KMC services are tracked through the national health information management system, which in 2015 was strengthened to include core indicators and standardised national registers, as well as reporting forms for KMC. Today, KMC continues to be highlighted in guidelines, trainings, and campaigns to reduce the number of preventable deaths among newborns. The World Health Organization and UNICEF featured Malawi's progress in reducing neonatal mortality rates in the report Reaching Every Newborn National 2020 Milestones (2017). 3 It is crucial that Malawi continues to move forward by increasing the coverage of KMC services, mentoring staff, improving KMC data quality and data use, and disseminating the lessons learned from the KMC centers of excellence. The majority of public hospitals implement KMC. The establishment of sick newborn care units in all the district hospitals is ongoing. However, there is a gap in coverage of KMC in private for-profit hospitals.
All government-owned tertiary and district hospitals offer facility-based KMC services, but it is difficult to estimate whether KMC is fully operational due to inconsistent reporting through the DHIS2.

Percentage of LBW newborns initiated in facilitybased KMC
Using data from the 2014 emergency obstetric and newborn care (EmONC) survey, an analysis of KMC readiness showed that KMC initiation rates for all live births for facility deliveries at hospitals ranged from 0.6% to 17.4%. 8 In 11 districts, it was estimated that in 2014 16% of preterm/LBW newborns were initiated in facility-based KMC. 9 About 21% in 2015, 19% in 2016, and 18% in 2017 of preterm/LBW newborns were initiated in facilitybased KMC in 11 districts in 2016. 9 It is estimated that less than 10% of preterm/LBW newborns are initiated in facility-based KMC, according to data extracted from maternity reports within DHIS2. There are issues with data quality including inconsistencies and lack of reporting that might result in underestimation of the initiation rates.

Funding
Funding for KMC is a combination of donor and MOH funds. Government funds come as reproductive, maternal, newborn and adolescent health, and Funding for KMC continues to be a combination of donor and MOH funds. Donor funds support training and mentorship/supervision activities, while they are not specific to intervention areas. However, most of the KMC capacity-building efforts and supplies are procured and distributed through partners, while government funding covers staff salaries. Funding gaps for KMC are mostly in creating neonatal units of care, increasing the quality of care of LBW newborns, and advocating to prioritize KMC. staff working in KMC units and referral hospitals are paid with government funds.

Research
Major or programbased studies currently being conducted related to KMC Several studies and program-based learnings were conducted prior to or during 2014 including:  Readiness of hospitals to provide kangaroo mother care (KMC) and documentation of KMC service delivery: analysis of Malawi 2014 emergency obstetric and newborn care (EmONC) survey data. 8

 Evaluation of Kangaroo Mother
Care Services in Malawi. 10 There are a series studies being conducted on KMC. These include:  Born too small: who survives in the public hospitals in Lilongwe, Malawi? 11  Investigating preterm care at the facility level: stakeholder qualitative study in central and southern Malawi. 12  Assessment of early outcomes among newborns discharged from facility-based KMC in three hospitals (SNL).  Evaluation of the use of a customised wrap to improve the uptake of skin-to-skin practices (SNL/Save the Children Norway/Laerdal Global Health).  Assessment of the completion and quality of data collected on birthweight at health facilities (London School of Hygiene and Tropical Medicine [LSHTM]/SNL).  Evaluation of approaches to improve measurement of service  A multi-country study (India, Malawi, Nigeria and Tanzania) is being conducted to assess the effect of continuous KMC when initiated immediately after birth compared to current practice of initiating KMC after stabilisation. The study has been ongoing since November 2017 and is scheduled to end in July 2020.  In Balaka, an assessment on family compliance with continuing KMC at home following discharge generated evidence to help families to continue KMC at home.  The study Starting the conversation: community perspectives on preterm birth and kangaroo mother care in southern Malawi found that KMC mothers and fathers only learned about KMC and care for preterm newborns after delivery of a child in need of this care. 13 The series of studies about KMC implementation in Malawi has been completed. The findings were readiness for small and sick newborns (LSHTM/SNL).  Malawi is a site in the Immediate Parent-Infant Skin-to-Skin study (IPISTOSS) looking at initiating KMC in unstable babies.
presented at the SNL KMC conference:  A study about improving uptake using customised KMC wraps found that among those who used the customised wraps in skin-toskin practices in facility KMC improved. Some 44% of mothers using a customised wrap reported 20 or more hours per day compared to 33% of mothers using the traditional chitenje. 14  A study on early outcomes among newborns discharged from KMC showed that follow-up visits averaged 88% but varied by site.
One of the barriers to follow-up compliance was the distance to the facility according to mothers enrolled in the study. 15  Regarding data availability, a simplified KMC register and reporting form was developed followed by a quality assurance exercise. Annual data reporting improved with 87% of hospitals submitting KMC reports compared to 51% hospital submissions in 2014. However, data quality issues persist. 16  A study about improving quality of newborn care at a district hospital found that a reduction of 6% in neonatal death rate between 2015 (15.5%) and 2016 (9.5%) was observed after making improvements to quality of care which included mentorship of service providers, availability of equipment and supplies, increase number of beds in the newborn care unit from three to 40, and monthly data audits. 17

Knowledge Management
Centers of excellence or state-of-the-art facilities for KMC/care of LBW babies Two health facilities considered KMC centers of excellence: Queen Elizabeth Central Hospital and Thyolo District Hospital. Lessons learned from these centers include that leadership should promote KMC as a priority, staff should be identified at the health facility to be trained on KMC, and improvement should be showcased when providers report and document the progress of KMC babies.
Queen Elizabeth Central Hospital and Thyolo District Hospital continue to be the two KMC centers of excellence in the country.

KMC indicators included in the national HMIS
Thirty-two data elements were collected, but standard indicators were not defined in the DHIS2.
The DHIS2 monthly reporting forms were revised, and eight data elements and five core KMC indicators were included in 2015.
The KMC indicators currently being monitored are:  KMC initiation rate: number of babies initiated in KMC (inpatient and/or ambulatory) per (i)100 livebirths at health facility and (ii) 100 LBW/premature babies identified at health facility.  KMC referral completion: Proportion of babies who were initiated in KMC, referred and completed referral, and were initiated in facility based KMC.  Survival to discharge: Proportion of babies initiated in facility-based KMC who are discharged alive.
 Death before discharge: Proportion of babies initiated in facility-based KMC who died before discharge.  Left against medical advice: Proportion of babies initiated in facility-based KMC who left against medical advice or abscondment.
KMC data recorded at health facilities Some facilities used a KMC register developed by the MOH, Save the Children and partners. KMC has been part of the integrated supervision at national, zonal and district levels. KMC registers were used by some health facilities receiving partner support to track KMC services. The 2014 EmONC was the first survey to capture information about KMC services at the national level.
 In 2015, a national routine reporting system for KMC services was rolled out to replace the original KMC register and monthly report. This reporting system, comprising a register and a monthly report, tracks KMC services at the facility and district levels. Facilities report on six data elements with inpatient KMC, two data elements without inpatient KMC, and five core indicators. 20 According to an analysis of the DHIS2/health PACHA advocated for KMC by introducing the COIN training course, which integrates essential newborn care and LBW baby care. 9 As of 2016, PACHA was providing KMC mentorship in ten district hospitals.

Champions
Dr. Queen Dube, paediatrician at the Malawi College of Medicine, attended the Istanbul Convening for KMC Acceleration and was an early KMC champion in Malawi.
 There are strong local champions who promote KMC, one of them being the Chief of Health Services. There is a strong presence at the national level for KMC but a lack of resources.  Dr. Queen Dube has mentored three national-level paediatric and midwife mentors who help her to provide mentorship, coaching and supervision to district hospitals for newborns.

Table 2. Demographic and Health Survey (DHS) proxy indicators for kangaroo mother care (Malawi DHS 2015-16) 21
Identification of LBW Babies Characteristic Percentage Percentage distribution of live births in the 3 years preceding the survey by mother's estimate of baby's size at birth, according to background characteristics  Local champions, including the MOH, with a track record of promoting KMC, play an influential role in scale-up and improving quality of newborn care.  Improving health management information system data quality for KMC services will allow Malawi to identify gaps in coverage, quantify achievements, and mobilise resources for KMC better.  The commitment of the MOH, partners and other stakeholders is critical for KMC to increase coverage and be sustainable.  2 The Neonatal Protocols manual outlines that healthcare providers should encourage all mothers of stable LBW babies (< 2,000 g) to provide KMC to prevent hypothermia, enable frequent breastfeeding, and allow for an earlier hospital discharge. The Essential Newborn Care Reference Manual describes KMC along with its advantages, its discharge criteria, and the importance of follow-up within 1 week of discharge from the district hospital. 3 As the country transitions from the scale-up of KMC services to sustainability and quality, there are opportunities for improvement regarding the roll-out of follow-up after discharge and improving data quality.  Percent Percentage of children born in the past 2 years who started breastfeeding within one hour of birth 80.5 Percentage of children born in the past 2 years who started breastfeeding within one day of birth 95.7 Skin-to-Skin Contact Percent Percentage of births that had skin-to-skin contact for the most recent live birth in the 3 years preceding the survey N/A CHALLENGES  There are major funding gaps for KMC, a need for more beds and space for KMC in some hospitals, lack of food at hospitals for new mothers and a lack of formula for LBW babies.  It is not always possible for mothers to bring the babies back to health facilities for check-ups due to long distances and lack of access to transportation.  There is a shortage of staff to conduct monitoring during hospitalisation.
LESSONS LEARNED  The strong leadership from the MOH and the support of partners and other stakeholders have been essential to the scale up of KMC. KMC has been integrated into national policies and guidelines, as well as in the HMIS and registers.  WhatsApp is used in some districts to follow up with mothers of LBW babies.  KMC messages are disseminated via radio, community gatherings and theatrical presentations.
FUTURE ACTIONS  Continue training health providers because there is a high turnover of personnel.

Status of facility-based KMC activities in other countries of interest and the Dominican Republic
Eight countries of interest and the Dominican Republic participated in the assessments.

Number of LBW newborns and KMC initiations by year and region
 It is estimated that over 75% of newborns are placed in immediate skin-to-skin contact after delivery and prior to cutting the umbilical cord. After the cord is cut and the baby is dried, the baby is returned to the mother's chest. The newborn health national guidelines recommend skin-to-skin contact as a practice that should be initiated at birth. Lack of space at the health facilities for in-patient care, lack of resources (for example, food or transportation) to support mothers who need in-patient or ambulatory care, limited job aids and tools and the need to provide more trainings and refreshers for providers to ensure sustainability.

Future Actions
 Continuous reinforcement of KMC skills especially in basic emergency obstetric and newborn care (BEmONC) facilities and systematic integration of KMC in maternal and newborn health services.  National policies, norms and procedures on KMC need to provide specific directives for all health system levels (national, regional, district hospitals and community health centers).  The KMC register needs to be validated nationally and integrated in national forms/registers. The register should include KMC follow-up information.

Status of facility-based KMC activities in Mozambique
Participants provided information in 2014, 2017 and 2019. Policy  KMC is included in strategic documents on child health including essential care for newborns and in packages of continuous training for maternal and neonatal care.  The newborn care action plan (ENAP) has been approved. The ENAP includes guidance on KMC. Country Support/Implementation  KMC implementation is low (10-< 25%) given that most births happen at the health facilities in the lowest tier, which lack the infrastructure to care for preterm/LBW babies.

Monitoring and Evaluation 
KMC indicators are not yet included in the national HMIS and the percent of premature newborns who receive KMC is only tracked at the program level.  Standardised KMC registries are being developed.  The Ministry of Health (MISAU) periodically collects information on KMC at the health facility during evaluation activities.

Knowledge Management 
A pocket-book for the care of hospitalised newborns will be finalised in early 2020. Advocacy  The Associação Moçambicana de Pediatras (AMOPE) is one of the professional organizations that endorse KMC. Supported by UNICEF, AMOPE has been involved in trainings about caring for preterm and sick babies in three provinces, and it is collaborating in the development of the pocket-book about caring for sick newborns.

Challenges 
Although KMC must be practiced in all health facilities (public or private) the lack of space, mostly in primary healthcare facilities, limits KMC implementation.

Future Actions 
To scale up KMC, it is critical that the MOH with the support of partners and professional associations conducts trainings, increases the availability of human resources, develops materials, purchases equipment and designates spaces for KMC. There is no uniform policy for KMC implementation, and as of today, all partners implement and monitor KMC activities separately. Country Support/Implementation  KMC is relatively new in Pakistan. MCHIP through Save the Children started implementing KMC as a pilot in 2017 in one hospital: the Gambat Institute of Medical Sciences (GIMS) in Khairpur. Later, the District Headquarters Hospital in Shikarpur started offering KMC services, but due to lack of funds, the program closed.  Currently, KMC is practiced in two government hospitals: GIMS, Khairpur and the Jacobabad Institute of Medical Sciences (JIMS) in Jacobabad district. This implementation is led by the Department of Health (DOH) with support from Save the Children.  KMC funding is a combination of donor and MOH funding.

Monitoring and Evaluation 
There is no system in place to track availability of facility-based KMC services.

Knowledge Management 
A qualitative study to identify barriers and enablers for practicing KMC in rural Sindh was conducted. Two hospitals were included in the study: the CEmONC hospital GIMS in Khairpur district, and the District Headquarters Hospital in Shikarpur. The key facilitators for practicing KMC were ownership of hospital management, close coordination between the obstetrics and paediatrics departments, involvement of community health workers, strong linkages between hospital and community health workers, presence of a counsellor and trained staff in KMC units, and ensuring privacy, food and security for female attendants. Lack of government support, unwillingness of hospital staff, poor follow-up processes after discharge and weak data management and analysis are few of the barriers listed in the study. 26 Advocacy  Save the Children Pakistan developed a short film on KMC implementation experience, which is widely accepted in the country. Challenges  Lack of funding. Future Actions  Political commitment will be essential in the upcoming years to scale up KMC.  There is a high level of acceptance of KMC within government and community; unfortunately, there is a lack of funds either to continue KMC in the two existing hospitals or to plan for further scale-up in other districts. The DOH is drafting a "National policy on the quality of care for small babies: accelerating the reduction of newborn deaths," which focuses on small babies. Training of healthcare providers focuses on the prevention of the complications of prematurity and LBW, the importance of early initiation of KMC at birth, and its continuation. 

Status of facility-based KMC activities in the Philippines
The DOH is currently updating the Philippines Newborn Action Plan 2030 to address the acceleration of improvement of quality of care for small babies. Country Support/Implementation  It is estimated that 58% of preterm babies and babies weighing 2,000 g or less in national hospitals, and 38% in subnational hospitals are initiated in KMC. 6


About 28% of small babies in national hospitals, and 48% in subnational hospitals, are initiated in immediate skin-to-skin contact. 6


The number of KMC service delivery points has increased significantly from 21 in 2013 to 145 in 2020. This was achieved through collaborative efforts between WHO, UNICEF, DOH, the KMC Foundation Philippines and the Association of Philippine Schools of Midwifery (APSOM).  KMC initiation, as part of delivery room resuscitation has been incorporated into the Neonatal Resuscitation Philippines Plus (NRPh+) of the Philippine Society of Newborn Medicine and endorsed by the Philippine Paediatric Society as its official training module for paediatric residents, neonatology fellows-in-training and consultants renewing their NRP providers' status.

Monitoring and Evaluation 
A system for integrating services such as the availability of facility-based KMC services, prevention of complications of prematurity and low birthweight, basic newborn resuscitation, and community mobilisation into the monitoring system has started.  KMC data is recorded at the health facilities through a KMC Audit Form. KMC indicators have not been included in the hospital information management system (HIMS), but there is a plan to collect the data in a more systematic way at the DOH level. Funding  KMC activities are funded through a combination of development partners and DOH funding, although most of the funding is from the DOH. There are gaps in funding quality improvement activities.

Knowledge Management 
A health insurance package for preterm and small babies, "Z Benefit Package for Preterm and LBW infants," was developed in collaboration between the DOH and the Philippine Health Insurance Corporation (PhilHealth) with technical assistance from UNICEF.

Challenges 
A challenge in the scale-up of KMC nationwide, has been the regional scale-up to the local government unit level because some areas are geographically isolated and disadvantaged.  Lack of human resources for health at the subnational and local government unit level to provide technical assistance to health facilities and health workers hamper the further scale-up of KMC. Future Actions  The next steps are for regional centers of excellence in KMC/CSB to collaborate with the DOH to roll out KMC to all Level 2 and Level 3 hospitals.  The DOH and PhilHealth will facilitate the implementation and availability of the national health insurance package for premature and small babies nationwide.  Each center of excellence will integrate the KMC data base into their HIMS starting 2020

Status of facility-based KMC activities in Uganda, Vietnam, and Tanzania
Participants provided information in 2014 and 2017.

Status of facility-based KMC activities in Uganda
Initially, KMC was implemented on a small scale in Uganda. Later, SNL used KMC to increase the survival of small babies in western Uganda at the Regional Hoima Referral Hospital, where they set up a regional learning center and implemented KMC in lower level facilities. In total there are 11 facilities providing KMC. The MOH is currently reviewing how to adapt KMC indicators for inclusion in the National Newborn Care Guidelines. The SNL protocols and tools are being used in central Uganda in three districts where there are three KMC model sites in each district and KMC corners in six Level 3 facilities. Some of the challenges in implementing KMC have been the designation of KMC spaces due to limited space at the health facilities, being able to keep mothers on the ward until the baby reaches 1.5 kg, which is the discharge criterion because food is not provided for the mothers, and not having enough staff to monitor daily weight and temperature of the babies in KMC. The next steps are to finalise the KMC tools and guidelines to be scaled up.

Status of facility-based KMC activities in Vietnam
The progress achieved through partner organizations in the care of small babies served to plan for the scale-up of KMC. KMC is included in the Early Essential Newborn Care Guideline and in the National Guideline on RH services. Most tertiary, teaching, and secondary/district facilities provide KMC as well as some of the private hospitals. According to the 2016 MOH annual report, KMC services were provided in 60 of 64 provinces throughout Vietnam, and 36,708 preterm newborns received KMC services in 2016 (the total number of live children was 1,563,231). Funding for KMC activities is a combination of MOH and partner funding, but since Vietnam became nominated as a middle-income country, the funding sources to implement health projects have been significantly reduced. Currently the government is committed to scale up KMC integration with the EENC package. It is expected that Vietnam will update the KMC guidelines to include information about post-discharge follow-up services for preterm/LWB and to improve data quality in hospitals.

Status of facility-based KMC activities in Tanzania
There are KMC national guidelines and KMC is covered under newborn care services. However, KMC as a standard of care is not yet emphasised in newborn health policies. Approximately 20% of health facilities provide KMC services. The government set up a plan to scale up KMC but due to budget constraints, the scale-up has been delayed. Although KMC indicators are not included within the HMIS system, there is a separate KMC data register that is used at health facilities. One of the most significant achievements in increasing access to KMC services has been the recognition by the MOH of 11 centers of quality service provision and the setting up of KMC services in 25 hospitals in the provinces of Mara and Kagera. The next steps to scale up KMC in Tanzania will be to include KMC indicators in the HMIS system and to integrate KMC standards in the C/BEmONC as well as scaling up KMC in more health facilities with the support of partners.