Discussion
These five Ugandan health facilities, which included a national referral hospital, a district hospital, and three regional referral hospitals, all required substantial physical and human resource inputs to allow safe implementation of iKMC. Our findings raise doubts about the affordability of rapid, widespread scale-up of iKMC in LMIC settings. We found substantial variation in the cost of improvements per hospital, per neonatal admission, and per neonatal bed. Costs were lowest at the national referral hospital, which had been recently constructed. Given the range across these facilities, largely driven by the previously available infrastructure, it would not be appropriate to extrapolate to other hospitals based on simple averages or costs per bed from our study. A standardised 20-bed neonatal unit in Uganda could be expected to offer a level of care broadly comparable to the four district and regional referral hospitals in this study, which were of similar size (range: 14–30 beds), but not to that of the national referral hospital (To our knowledge, this study is the first to evaluate the process and costs of implementation readiness for iKMC in health facilities. Previous studies in Brazil, Colombia, Ethiopia, Indonesia, Mexico, Nicaragua, and the United Kingdom have consistently found that KMC provision among stable neonates resulted in cost savings for the hospital or health provider [Two recent studies of KMC implementation among stabilised babies also identified gaps in health facility readiness. In Bangladesh, a study at eight government health facilities found that infrastructure challenges, including unavailability of adjustable beds and toilets for caregivers, were common and none of the sites had all equipment necessary to provide high-quality KMC [The findings of this study should inform planning and budgeting for the setup of safe iKMC in LMIC settings, as well as decisions regarding where and whether to implement iKMC at all. This contribution is important because the vast majority of babies in sub-Saharan Africa and South Asia lack access to hospitals with neonatal intensive care [This study had strengths and limitations. The data are comparable across five facilities of varying service levels and sizes. Cost data were based on detailed activity records but were collected retrospectively. Data on staff time spent away from routine duties during planning, design, and training, which accounted for around one-third of additional economic costs, could have been subject to recall bias or misreporting. We included planning and design costs for all those who attended meetings and other activities, implying these costs could be lower if fewer people were involved. The HFA modules included in this evaluation assessed readiness of facilities to provide small and sick newborn care, with a focus on physical infrastructure and clinical equipment and supplies; we did not evaluate other health system building blocks included in the HFA tool, such as human resources, information systems, and administration and management, which are also imperative for the sustainable provision of high-quality care. Finally, some HFA data, particularly pharmaceutical products, had a considerable proportion of missingness, although we note that there are few pharmaceutical products necessary for WHO level-2 care.Policy decisions should be informed by thoughtful consideration of the level of neonatal care already available, including existing infrastructure, as well as the impact, cost-effectiveness, affordability, and sustainability of iKMC, and how these factors – and appropriate policy recommendations – may vary across settings. In a smaller trial in The Gambia, a before and after comparison showed a halving of neonatal mortality associated with infrastructure investments and improved quality of care; however, adding iKMC did not confer a significant mortality reduction [