Resilience in the face of crises: Evaluating the implementation of a digital healthcare tool for newborns in Zimbabwe.

Recent crises, including the COVID-19 pandemic, have put a huge toll on health services globally, particularly in low-middle income countries (LMIC). The importance of resilience in these health care systems in times of stress to be able to quickly and effectively respond is vital to their ability to save lives. In LMICs, such as Zimbabwe, improvements in child survival have been slender due to fundamental weaknesses in healthcare systems, including lack of skills and poor resource supplies. Challenges such as pandemics, industrial action and economic collapse further threaten health systems and thus newborn survival.
Cheap and straightforward methods of helping newborns (such as ensuring babies stay warm) are proven to improve survival, but for various reasons, including lack of training, may not be used effectively in hospitals and clinics. Smartphone and tablet technologies may be useful tools to help. The NeoTree is a tablet-based application (app) to prompt clinical care, provide education, collect information about babies, and feed data back to healthcare workers (HCWs) to encourage them to change practices where necessary. Since November 2018 the NeoTree has been used in Harare Central Hospital (HCH) neonatal unit, Zimbabwe's largest newborn tertiary care facility, delivering 12,000 newborns annually. The NeoTree is designed to improve the quality of care and thus survival for sick and vulnerable babies admitted to low-resource hospital settings.

During the period of the NeoTree implementation Zimbabwe has suffered several crises with substantial impact on the health service including economic upheaval, significant HCW industrial action and the COVID-19 pandemic. I will analyse hospital-based data collected through our existing digital system, the NeoTree; to see how these crises affect newborn survival. I will track and compare NeoTree data from HCH over a 24-month period reporting on certain factors such as; number of babies admitted and discharged home, number who die and survive and their diagnosis. I will use social science methodology including applying behavioural science theory and frameworks to answer what help and hinders HCWs to follow guidelines both in 'peace-time' and during crises. In-depth interviews with HCWs will explore how they have found using the tool and providing neonatal care during crises. I will also seek to understand how crises effect their beliefs and experiences of the healthcare system. Observation of HCWs using the tool during set timepoints will also be undertaken and will be recorded by an observer. This will help to answer "if" they are not using the guidelines or using the tool, "why not". This holistic picture will be used to guide appropriate national and local health systems interventions to deliver safe care for newborns during times of crisis. It will be used to feedback to the NeoTree team about potential improvements in real time. It will aid in the identification of strategies to overcome barriers to implementation in other sites across Zimbabwe and other LMICs.

The NeoTree project appears to be robust during economic and social upheavals, disease outbreaks and HCW industrial action, potentially due to the user-friendliness of the platform and committed local leadership from our African partners, at hospital and Ministry levels. Since the onset of the COVID-19 pandemic, the NeoTree system has continued to function, ensuring the capture of key information about babies and their outcomes, while providing HCWs with emergency care support. However, detailed assessment of crises on both how the tool is used and the quality of the data captured has not been carried out. This evaluation - how external factors effect newborn care and the use of the NeoTree , is required to provide an understanding of the delivery and use of the NeoTree (and similar interventions) in our target countries, where challenges are frequent and varied and how to make it successful.

Crises, such as the COVID-19 pandemic, will lead to excess mortality and morbidity in newborns in low-income settings, damaging recent improvements in care and survival. Few robust data exist to explore these impacts in Zimbabwe. Interventions to improve newborn care in these settings, where challenges are frequent and varied, must be resilient to be useful and require contextual process evaluation specifically during times of crises.

I propose to undertake a mixed methods evaluation of an existing digital newborn quality of care intervention (the NeoTree) to support healthcare workers (HCWs) in clinical management of newborns during times of extrinsic challenge. The NeoTree has been embedded in daily clinical practice in Zimbabwe's largest neonatal unit. It provides data capture, education, clinical support and linkage to local data dashboards. Implementation is ongoing in a second Zimbabwean hospital. During the period of the NeoTree implementation Zimbabwe has suffered from several crises with substantial impact on health service delivery including economic upheaval, significant HCW industrial action and the COVID-19 pandemic. I will use quantitative neonatal data (from the NeoTree) to track and compare trends in case fatality rates, admission and discharge diagnosis during times of extrinsic challenges. An assessment of how the quality of data changes over time both with missingness and accuracy will also be reviewed. These data will be combined with both structured observation and qualitative interviews with HCWs to explore experience of health service delivery and use of the tool, specifically during times of crises. The triangulation of quantitative, data quality, qualitative and ethnographic data will provide actionable insights into implementation for local health systems and national health policy leads; "crisis implementation science".