Train-&-link

Substandard newborn care continues to be a critical problem and factor in poor newborn outcomes in rural Uganda. The train-&-Link team believes that every newborn should have access to high-quality care services, regardless of location. Despite some progress made in achieving this goal over the past few decades, most of it has slowed or even reversed, and newborn deaths still account for half(2.3million) of all deaths among children under-five years worldwide.

A newborn death is the death of a child within the first 28 days of their life. Most newborn deaths occur within the first week of life, and approximately one million in the first 24 hours. In 2022, Sub-Saharan Africa led with 27 deaths per 1000 live births, compared to the global average of 18 deaths per 1000 live births. Children born in this region have an eleven-times higher risk of death compared to those born in high-income countries. The risk is 56 times higher in the country with the highest mortality rate here than it is in the country with the lowest mortality rate in the developed world - babies born in remote, low-resource areas or during humanitarian crises are the most affected and the leading causes are preventable, they include preterm birth, birth complications(birth asphyxia/trauma), neonatal infections, and congenital anomalies. These factors account for almost 4 out of every 10 deaths in children under-5 years, and reports state that poor-quality health facility care was one of the leading reasons for newborn deaths.

In Uganda, 27 deaths per 1000 live births are seen for the past decade. The Uganda Ministry of Health (MoH) adopted the Essential Newborn Care package, with easy-to-use, affordable, and suitable interventions for caregivers and caretakers alike, despite the concerted effort, MDGs were not achieved. Frontline implementers continue to lack the skills and knowledge to carry out these initiatives and access to mentorship is limited. 

Though mentorship is known to improve knowledge, skills and improve care standards, the existing programs create limited opportunities for continuous professional development beyond pre-service training - do not give room for joint participation in everyday patient care; and limit after training team-interaction hence limiting knowledge transfer and sharing. This coupled with the shortage of specialist or experienced teams in these environments make it difficult for babies to access needed interventions. It in-turn prevents babies from receiving high-quality care when they need it, resulting in needless suffering and fatalities.

Kachumbala Health Center 4 in Bukedea district exemplifies this problem - three baby deaths for every 100 live births occurred in 2022 and the causes included prematurity, infections, and failure to breathe at birth, all of which were entirely preventable and/or treatable. The baseline study conducted that year attributed the high mortality to gaps in the knowledge and skills among local caregivers to resuscitate, treat, and manage newborn babies  and rarity of local training and mentorship programs.

Newborn survivorship could significantly increase if frontline caregivers were supported adequately to provide prompt high-quality care.

Our solution is to "Train-&-Link". This initiative empowers frontline caregivers with Essential newborn care knowledge and skills. We train midwifes, clinical officers and nurses at the level of frontline local facilities and connect them with peers and experts to facilitate digital consultations, digital mortality evaluations, end-to-end communication during referrals, a feedback loop between high-end, lower-end systems and continuous medical education; a collection of activities that allow for continuous, uninterrupted post-training professional development. 

We provide the solution in two ways: 

1) Basic Training: We customize previously created training modules, which are simple to read, comprehend, and instruct. Since government facilities provide health care to the majority of Ugandans, especially in remote areas(approximately 88.13% of Ugandans in the poorest quintile and 81.46% of Ugandans in the second poorest quintile), we use these modules to teach caregivers at the level of frontline public care facilities. 

2) A Digital Platform: Consultative and death review sessions, end-to-end communication during referrals, and joint-case management can be arranged between frontline or lower-end and specialist or high-end teams via free digital services like Google Meet, Zoom, and WhatsApp. 

The services offered through this program include community-level consultations and newborn management, primary care provider to specialist e-consultations, case reviews, and sharing of information during referrals to allow preparedness from the receiving end. 

Here's how the program works: 

- The caretaker consults the caregiver in the local health facility. 
- The baby is examined by a trained caregiver. 
- If the case is complicated, the caregiver makes an appointment with the specialist via phone or text message using the communication platform. They include the sick baby's history, clinical, and investigational findings (if any) in their consultation request. 
- The sick baby's clinical presentation can be captured on camera or in video, which the caregiver can upload to the page. 
- After reviewing the baby's medical data, which includes photos and videos, the specialist or another experienced clinician can diagnose the baby's condition and provide the caregiver with advice on the best course of action. 
- If it is decided to refer the newborn, the trained/primary caregiver notifies the next referral site in advance so that they are prepared. The patient's past and present medical records are also readily available online, should that be necessary. The referring clinician may receive feedback from the referral site. 
- The specialist can then directly assist the primary clinician in case management if no referral is needed. If needed, the specialist can assess the infant remotely, and the team can perform a mortality review if necessary. 
- If necessary, the separate platforms can coordinate the emergency team and emergency (ambulance) transfer.

Train-and-Link is designed for last mile care providers and it aims to equip approximately 32,100 rural healthcare workers in Uganda with skills to provide better care to newborns through training and mentorship and harnessing the power of social media to make continuous mentorship sustainable. These healthcare professionals provide direct care to infants from their communities with support from specialists and all together more than 39 million rural resident will benefit.

Our solution decentralizes specialized newborn care by empowering local caregivers. This enables immediate, high-quality, and affordable newborn care for low-resource, vulnerable communities without the need for specialists to be present. The program empowers last-mile public health facilities to become newborn care units with committed and empowered care providers.

In 2023, we launched the program and helped train and connect 20 staff of Budaka Health Center 4, where we trained 20 local staff members and established a newborn care unit. By increasing teamwork and enabling personnel to recognize neonates in need of immediate resuscitation, referral, and treatment, we minimized neonatal fatalities by 25% by the year end.

The train and Link team works as an expert team of clinicians leading in the management of newborn babies in the Elgon region of Eastern Uganda. We demonstrate evidence based, locally designed newborn care interventions.

Our initiative was deployed in Budaka health center 4 where we trained 20 midwifes and nurses on basic newborn care interventions.

The team consists of 6 newborn experts with vast experience in newborn care, project planning, implementation and monitoring that we have gained over 5 to 10 years depending on an individual. we work closely with the Mbale Regional Referral Hospital in Eastern Uganda. 

Some members in our team sit on national steering committees to generate policy and guidelines in newborn management.

The idea was tested at Budaka health center 4 and we were able to register success in attendance, support from the facility and district leadership and associated improvement in newborn outcomes following the training and mentorship. we are iterating on our business/ project model.

We hope to become visible, network with the research experts/community, develop our own program application - both the android (for frontline) and web (for mentoring team) applications & integrate with related technologies, and obtain mentorship.

Where necessary we hope to receive funds to help expansion of our training programs and the integration of this new effort within the Ministry of Health newborn care platforms.

To achieve broader impact, training alone is not enough. The existing mentorship programs train and the trainers leave until the next training date. This gives room to easily forget what was learnt. The approaches are also not sustainable since every movement to the field requires facilitation.  Success and effective knowledge transfer requires continuous follow ups until the trainees have mastered the art. Our approach therefore :

1) Enables continuous follow-up and mentorship online  through shared management of babies with an expert and through meetings such as death review meetings, continued medical education, and feedback loops. This makes it 10 times a more effective mentorship program than traditional mentorship programs.

2) It cuts down on the cost of follow-ups by approximately 70% by leveraging the power of social media and online meeting platforms allowing as to follow up and supervise at the minimal cost possible.

3) By allowing interactions between caregivers, we can also ensure that babies are properly tracked during referral.

4) It fosters a team spirit between high end and lower end care givers and between peers and interactions between facilities.

5) Lastly our training manuals remain with trainees to act as the reference point incase any thing is forgotten, with backup from specialists. 

Our approach is to train frontline caregivers and provide them with access to a network of peers and experts. We also create awareness in communities on the existing newborn care services through the village health teams. 

Training and connecting provides a platform for frontline caregivers to gain, retain, and improve their knowledge and skills in managing newborn babies. This results in trained caregivers who are equipped to provide high-quality newborn care even in low-resource and remote communities and this coupled with beneficiary awareness drives increased demand for services. 

This approach not only enhances the quality of care that newborns receive but also immediately stops fatalities from preventable and curable causes. Over time, it also minimizes or prevents complications, leading to better growth and development outcomes for newborns. By using the train-and-link approach, we have been able to reduce newborn deaths by 25% through 2023 in Budaka Health Center 4.

Evidence has shown that locally led initiatives that invest directly in healthcare provider education and health systems strengthening represent a promising avenue for reducing neonatal morbidity and mortality

Activities:

The number of annual training sessions conducted per facility and the development of communication platforms.

Output:
The number of caregivers who have been trained and connected.

Outcome:
Immediate - The ability to demonstrate knowledge and skills in basic newborn care, such as identifying neonates in need of urgent care and monitoring or referring them, reconstituting and administering essential medications, recognizing the basic supplies and equipment required for newborn care, and performing neonatal resuscitation.

Intermediate - Improved quality of newborn care.

Long-term - Reduction in the number of newborn deaths.

General outcome: The number of babies visiting the facility? how many received the care they needed? and what percentage succumbed to their illness?

Impact:
Short-term - For all the surviving babies, how many attain their developmental milestones including: Physical growth; cognitive development; emotional and social development; language development; and sensory and motor development.

Long-term - improved quality of life; human capital for community development.

Train-&-Link uses two technologies: first, we look for evidence-based, proven life-saving newborn care interventions and teach caregivers about them, and then we improve their performance by leveraging digitally freely available social platforms to promote team communication and continued mentorship.

6 and training more for recruitment into our team.

3 years

We have a team of 6 full time members who are all healthcare providers and experts in newborn care, our aim is to grow this team further to make it an interdisciplinary team and we are continuing to grow a portfolio of activities that will enable the smooth running of the project including App developers, public health specialists, designers, communication experts, field monitors, data analysts, etc.

Currently all the 6 members are Ugandan nationals. We have embraced gender balance within our team, with the ratio of male to female being 1:1. 

Together, we have spent over 26000 hours co-creating our solutions with frontline partners.

We adopt a diversified approach to raise funds, which includes receiving donations and grants, fundraising, and selling training modules to interested individuals. Grants are used to take care of fixed expenses such as purchasing training tools, while revenue generated from fundraising and selling training modules is used to cover operational expenses such as the facilitation of trainers and trainees, including transportation and welfare. Our services are recognized and utilized by the government, who partner with us to create a significant impact. We plan to continue using this blended approach, which includes entering into agreements with organizations interested in scaling or implementing our solution.

Our plan employs a blended revenue approach including:

1. To continue generating a strong backup of evidence on impact; to align well with government policy so as to attract a government partnership  and funding. 

2. Establish more local fundraising platforms and create a unit responsible for this and ensuring that the monitoring and evaluation team is created for identification and donor relationship as well as improved impact reporting

3. Raise funds through grants from NGOs / foundations.

5. Writing and selling manuals to all that are interested and affordable cost