The NEST360 alliance supports neonatal units in the four study countries with a coordinated package of technologies, training, data systems and quality improvement methods aimed at reducing newborn deaths. Yet even within this structured program, coverage of priority interventions varies widely from one hospital to another. Coverage, in this context, means the percentage of eligible newborns who actually receive a given intervention. The four interventions examined were kangaroo mother care, in which a low-birth-weight baby is held skin-to-skin on the mother’s chest for warmth and bonding; continuous positive airway pressure, a breathing support delivered through gentle pressurized air for babies struggling to breathe; phototherapy, which uses blue light to break down excess bilirubin in jaundiced infants; and hypothermia prevention, the set of practices that keep fragile newborns warm enough to survive.

To identify what distinguished the best performers, the research team used a positive outlier design, a method that deliberately seeks out units achieving unusually strong results and asks what they are doing differently. Hospitals were selected on the basis of their coverage rates for at least one of the four interventions, with rapid improvement or sustained high coverage defining success. The evidence base came from an unusually rich qualitative dataset: 74 key informant interviews and 21 focus group discussions spanning 16 hospitals in four countries. Respondents included clinicians, managers and other staff who run these units day to day. Transcripts were analyzed using both deductive coding, guided by existing implementation science frameworks, and inductive coding, which allowed new themes to emerge from the data themselves.

The headline finding is striking in its sheer scale: the researchers identified 114 distinct strategies that high-performing hospitals used to achieve and maintain high intervention coverage. That number alone tells an important story. Getting a lifesaving therapy to every eligible newborn is not a single act but a dense web of behaviors, routines and relationships that must function together, shift after shift, day after day. Many of these strategies were low-cost, which is perhaps the most consequential finding of all. They did not depend on new machines or additional funding streams. Instead, they targeted organizational and behavioral mechanisms: motivation, accountability, teamwork and the everyday habits that determine whether a device sitting in a corner actually gets used on the baby who needs it.

Three strategies appeared again and again across all four countries, forming a kind of common grammar of high performance. The first was peer-to-peer mentorship, in which experienced staff coached colleagues informally rather than relying solely on formal training events. The second was routine data review meetings, where teams regularly sat down together to examine their own performance figures and decide what to fix. The third was family education, ensuring that mothers and caregivers understood the interventions, from the mechanics of kangaroo mother care to the importance of keeping a baby warm, so that families became partners in care rather than passive recipients. Each of these practices costs little, but together they create a feedback loop: staff learn from each other, data reveals problems, families reinforce correct practices at the bedside.

Alongside these shared strategies, the study documented country-specific adaptations that reveal how local context shapes implementation. In Malawi, hospitals placed particular emphasis on data-driven decision-making, building routines around the systematic collection and interpretation of unit-level information. In Tanzania, the standout theme was infection prevention and control, reflecting the acute danger that hospital-acquired infections pose to vulnerable newborns whose immune systems are immature. These differences matter because they demonstrate that there is no single template for success. The high-performing units did not copy one another; they adapted a common set of principles to their own epidemiology, staffing patterns and institutional cultures. For program designers, this argues strongly for flexibility rather than rigid standardization.

Beneath the specific tactics, the researchers found a deeper pattern. High performance appears to be driven by staff empowerment, interdisciplinary collaboration, continuous learning and data-driven accountability. Empowerment means that nurses and junior clinicians felt able to raise problems, propose changes and act without waiting for permission from distant administrators. Interdisciplinary collaboration means that doctors, nurses, midwives and biomedical engineering technicians worked as a coordinated team rather than in professional silos. The inclusion of biomedical technicians is notable: in low-resource settings, broken equipment is one of the most common reasons lifesaving devices sit unused, and units that maintained close working relationships with the technicians who repair and maintain their machines kept their continuous positive airway pressure devices and phototherapy units running far more reliably.

Continuous learning and data-driven accountability deserve particular attention because they transform the unit’s relationship with its own performance. In the hospitals studied, data was not collected merely to satisfy reporting requirements to ministries or donors. Instead, teams reviewed their coverage figures routinely, treated shortfalls as problems to be solved rather than failures to be hidden, and tracked whether changes actually improved outcomes. This creates what implementation scientists call a learning system, an organization that improves itself through cycles of measurement, reflection and adjustment. Accountability in these units was largely internal and collegial, rooted in shared commitment to the babies rather than imposed from above, which may explain why it proved durable where externally mandated targets often do not.

The implications reach well beyond the NEST360 network. Global health programs have historically concentrated on supplying the hardware of survival: incubators, radiant warmers, oxygen concentrators, training curricula. This study adds rigorous qualitative evidence that hardware alone does not close implementation gaps. As the authors conclude, beyond program interventions like trainings and medical devices, strategies fostering staff engagement, leadership support and cultural alignment are critical to achieving and sustaining high coverage. In other words, the binding constraint in many low-resource neonatal units is not technology but the organizational fabric that determines whether technology is used consistently. The 114 strategies catalogued here offer an actionable menu for other hospitals, ministries of health and implementing partners seeking to strengthen small and sick newborn care, and because most are low-cost, they are feasible even where budgets are severely constrained.

The stakes could hardly be higher. Most newborn deaths worldwide occur in low- and middle-income countries, and the majority could be prevented with existing, evidence-based interventions that simply fail to reach every baby who needs them. By illuminating what the best-performing hospitals actually do, this study shifts the conversation from what to buy to how to build teams, habits and cultures that save lives. The positive outlier approach, studying success rather than deficit, proves its worth here: the answers were not in the equipment catalogs but in the daily practices of empowered, collaborative, data-literate teams. If those practices can be adapted and spread, the gap between what newborn care could achieve and what it currently delivers may finally begin to close, one hospital at a time.

Subject of Research: Facility-level implementation strategies for small and sick newborn care in high-performing African hospitals

Article Title: Understanding facility-level implementation strategies in high-performing hospitals for small and sick newborn care: a qualitative positive outlier study across four African countries

Article References: Dougherty, K., Ogueji, I. A., Mwaniki, H., Baraka, J., Ngwala, S., Mangwiro, L., Malla, L., Johari, M., Ezeaka, C., Kawaza, K., Tillya, R., Shamba, D., Oden, Z. M., Richards-Kortum, R., Rhoda, N., Lawn, J. E., Hirschhorn, L. R., & Bohne, C. A. (2026). Understanding facility-level implementation strategies in high-performing hospitals for small and sick newborn care: a qualitative positive outlier study across four African countries. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15621-9

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15621-9

Keywords: neonatal care, implementation science, NEST360, kangaroo mother care, continuous positive airway pressure, phototherapy, hypothermia prevention, quality improvement, positive outlier, Kenya, Malawi, Nigeria