High-quality neonatal care requires sufficient functional medical devices, furniture, fixtures, and use by trained healthcare workers, however there is lack of publicly available tools for quantification and costing. This paper describes development and use of a planning and costing tool regarding furniture, fixtures and devices to support scale-up of WHO level-2 neonatal care, for national and global newborn survival targets.We followed a systematic process. First, we reviewed planning and costing tools of relevance. Second, we co-designed a new tool to estimate furniture and device set-up costs for a default 40-bed level-2 neonatal unit, incorporating input from multi-disciplinary experts and newborn care guidelines. Furniture and device lists were based off WHO guidelines/norms, UNICEF and national manuals/guides. Due to lack of evidence-based quantification, ratios were based on operational manuals, multi-country facility assessment data, and expert opinion. Default unit costs were from government procurement agency costs in Kenya, Nigeria, and Tanzania. Third, we refined the tool by national use in Tanzania.The tool adapts activity-based costing (ABC) to estimate quantities and costs to equip a level-2 neonatal unit based on three components: (1) furniture/fixtures (18 default but editable items); (2) neonatal medical devices (16 product categories with minimum specifications for use in low-resource settings); (3) user training at device installation. The tool was used in Tanzania to generate procurement lists and cost estimates for level-2 scale-up in 171 hospitals . Total incremental cost of all new furniture and equipment acquisition, installation, and user training were US$93,000 per District hospital (level-2 care) and US$346,000 per Regional Referral hospital. Estimated cost per capita for whole-country district coverage was US$0.23, representing 0.57% increase in government health expenditure per capita and additional 0.35% for all Regional Referral hospitals.Given 2.3 million neonatal deaths and potential impact of level-2 newborn care, rational and efficient planning of devices linked to systems change is foundational. In future iterations, we aim to include consumables, spare parts, and maintenance cost options. More rigorous implementation research data are crucial to formulating evidence-based ratios for devices numbers per baby. Use of this tool could help overcome gaps in devices numbers, advance efficiency and quality of neonatal care.The online version contains supplementary material available at 10.1186/s12887-023-04363-w. Every Newborn Action Plan (ENAP) calls for countries to establish at least one unit providing level-2 care plus respiratory support with continuous positive airway pressure (CPAP) (referred to as level-2 care in this paper) in 80% of sub-national units  by 2025 [Hospital-based care for small and sick newborns has potential to avert approximately 750 000 neonatal deaths each year . Despite by 2025 . Standar by 2025 , 3. In a by 2025 . Level-1 by 2025 . Achievi by 2025 .Table 1Low-and middle-income countries (LMIC) are increasingly prioritising small and sick newborn care (SSNC) in national plans and targets , but theMany hospitals, especially those in resource-limited settings, have a shortage of functional medical devices and supplies. Historically, donated medical equipment has been relied on to meet this need, often without considering local constraints for training for use, maintaining, repairing, and decommissioning equipment. This has resulted in “equipment graveyards”, , 12. WhiCosting of medical devices requires determining the device types and quantities needed and unit cost data , 12. TheObjective 1: Review relevant planning and costing tools to assess content, design and costing approaches.Objective 2: Co-design content for a device and furniture planning and costing tool for a functional level-2 neonatal unit.Objective 3: Refine and use tool to estimate cost of national scale-up in mainland Tanzania.This paper is part of a supplement with the NEST360 Alliance, providing tools, analysis, and novel learning for implementing SSNC. In this paper, we aim to describe the development and refinement of a planning and costing tool. The intended audience is health planners at national, sub-national, or facility levels charged with planning and budgeting. The paper addresses three objectives:We searched for open-source planning and costing tools relevant to maternal and child health, including grey literature due to limited results in international bibliographies databases. Data extraction was informed by an adapted ISPOR Criteria for Cost(-Effectiveness) Review Outcomes (CiCERO) Checklist  Additio and was We engaged a multidisciplinary group of newborn care implementers with professional experience in LMIC  to inform tool development and ensure a user-friendly design. We defined criteria for the tool a priori and designed the branching logic framework to guide content and data inputs.A default 40-bed neonatal unit, including a ten-bed level-2 unit for care of small and sick newborns, was adopted from the Tanzanian newborn unit floor plan for a District hospital. In Tanzania, this level-2 care unit is known as the high dependency unit (HDU). The floor plan includes five rooms: the HDU/ level-2 care (ten cots), a general, step-down neonatal ward (ten cots), an isolation room (five cots), a kangaroo mother care (KMC) room (ten adult beds) and a rooming-in area (five adult beds)  (Table 2Remit to include the following components: 1) ward furniture and fixtures , 2) neonatal devices, and (3) training for use  , the UniTo identify types and quantities of devices to include in the tool for ten-bed level-2 care for small and sick newborns at District hospital, we reviewed several documentary sources , 27–30 aTo derive the price per device for a level-2 unit for the care of small and sick newborns, we followed a normative approach utilising market prices outlined by the government procurement agencies’ publicly available pricelists and requested quotes from private distributors in Kenya, Nigeria, and Tanzania. Median costs from government procurement agencies and private distributors were compared to assess variation. The government procurement agencies median cost was used as the tool’s default unit cost point estimate. Aside from government procurement agencies and private distributors, we identified the types of devices available from the UNICEF supply catalogue, though unit prices were not included due to variation in logistical costs e.g. freight across countries.Training is crucial for safe use and troubleshooting of devices. Based on our experience of implementing a SSNC package through the NEST360 alliance in 67 newborn units across four countries, we costed a one-day, facility-based training combining local health providers (clinicians and nurses) and hospital biomedical engineers and technician(s). We reviewed user training logs to inform the number of participants and copies of necessary training materials. To derive unit costs, we reviewed current government reimbursement policies and prevailing market costs  across three countries . Malawi (the fourth implementing country with NEST360) was excluded as it had achieved a national scale-up to exceed ENAP target 4. The median value was calculated and used as the tool’s default estimate. Some sparse data inputs were refined through expert consultation.The tool was used in mainland Tanzania, one of the few countries that met the 2015 Millennium Development Goal target 4 of reducing under-5 mortality by two-thirds. However, from 2010 to 2015, the national neonatal mortality rate (NMR) remained almost unchanged . This stTo achieve this target, the Ministry of Health sought to develop a national investment case for scale-up to the 171 hospitals, incorporating infrastructure, human resources, and other system costs . As partIncremental costs for District and Regional Referral hospitals were estimated separately in the tool due to differences in unit size, types and quantities of devices needed. Incremental quantities were estimated based on Tanzania’s national neonatal floorplans, District hospital costing assumed a 40-bed size with a ten-bed level-2 unit for care of small and sick newborns , whilst Regional Referral hospital costing was customised from the default to an 80-bed neonatal unit with 20-bed level-2 care unit  . The addData collection and report generation were led by a purposively sampled team of ten Tanzanians, representatives from the Ministry of Health and the NEST360 country team, with economists' support. The Tanzanian team  were engaged through informal and formal interviews to understand their experiences on usability, time burden, and perceptions of the tool’s content.Our findings and learnings are summarised according to the three objectives:The widely used costing and impact estimation tools; the Lives Saved Tool (LiST) costing module  and One LiST estimates lives saved through reproductive, maternal, newborn, and child health (RMNCH) interventions, and has more approximate costs to inform return on investment (ROI) estimates , 44. OneThe UNICEF Oxygen System Planning Tool was designed for a wider, non-specialist user group and focuses on incremental costs, primarily for set-up, and uses a stepwise approach, with easily customisable data input fields and a results dashboard , 42 (AddThe user-designed tool follows the Activity-Based Costing (ABC) to provide quantification and cost based on three components Fig. : (1) warA total of eighteen default furniture items were identified based on UN guidelines and national policies. The quantities required are shown in Table . RecommeUnit costs were derived from local government suppliers' absolute price ranges across Kenya, Nigeria, and Tanzania. The costs were consistent for fifteen items except for voltage stabilisers and uninterrupted power supply (UPS) which were relatively higher in Kenya, and refrigerators with freezer compartments and emergency trolleys were expensive in Tanzania. Of the 18-ward furniture and fixtures items, 11 (61%) had greater median prices amongst private distributors compared to local government suppliers Fig. a. The avA default list of 16 types of devices was reached through review and consensus agreement among a multi-disciplinary group Table . This deDevice quantification assumptions were based on a ten-bed level-2 unit with an option to customise. UNICEF neonatal care manuals provided guidance on number of devices based on the number of beds: UNICEF India for a 12-bed unit (22); UNICEF Bangladesh for a ten-bed unit 24); and UNICEF Sierra Leone for a ten-bed unit (25). The total number of devices ranged between 21 and 30 and were classified as either essential or desirable . Installation was assumed to be done by government-salaried biomedical experts.Across the 16 devices, the private distributor median unit cost for 12 (75%) devices were higher than that of the government procurement agencies  could be included if available. The training was delivered by two external facilitators – a nurse and a biomedical engineer/technician, government-salaried employees. Costed items were facilitator fees and travel reimbursement, refreshments and meals, and training materials  . Government per diem rates across the three countries were relatively consistent with ratio of lowest to highest per diem rate averaging 0.8. There was no variation in training input costs across countries. Data from 20 hospitals implementing with NEST360 showed nurses made up 50–75% of installation trainees drawn from newborn units, paediatric, maternity, and labour wards.We estimated an incremental scale-up cost  per District hospital at US$93,000 and US$346,000 per Regional Referral hospital. The higher cost of setting up a Regional Referral Hospital is attributed to increased unit capacity (10-bed to 20-bed level-2 care/HDU unit) that required more ward furniture, fixtures, and devices for level-2 care and additional devices for partial level-3 care. Partial level-3 care entails providing comprehensive inpatient special newborn care provided in secondary health facilities e.g., district hospitals plus some components of intensive newborn care services provided at the tertiary level of care, as defined by WHO Table . The totTool users in Tanzania had positive feedback on the stepwise tool structure and default entries of quantities and unit cost. They cited the need for additional guidance notes next to the data input fields to aid prompt and accurate data entry. On the other hand, non-clinical users reported difficulty understanding certain device descriptions and specifications and needed additional clarification and support. These concerns were refined in the tool and validated via a virtual walk-through session with the users.It took one week to collect and enter information  and generate the cost and procurement reports. All the users felt the reports were simple to interpret and could be incorporated into their budget planning processes.Implementing high-quality inpatient care for small and sick newborns requires sufficient, robust, context-appropriate devices and planning for user training and maintenance , 16. We Health system costing tools  had limited newborn-specific device inputs , which iUse of the tool in mainland Tanzania revealed feasibility for use by a non-economic expert to generate reports and results were able to catalyse additional investment in care for small and sick newborns. To scale up SSNC nationally in Tanzania, the estimated incremental cost per capita was US$0.23 for 146 District hospitals and US$0.14 for 25 Regional Referral hospitals. These are modest estimates when compared to scaling up community-based maternal and newborn care interventions in Tanzania (US$1.30), Ghana (US$0.40), and Malawi (US$1.00)  and malaStrengths of this work include the user-centric approach, systematic development of the tool, and transparency of the data sources. The tool’s customisability to reflect the local guidelines and costs, given the observed price variability and step-by-step approach with guidance notes, makes it feasible for use by individuals without an economics background. Reports generated by the tool, include minimum technical specifications of devices with corresponding product examples which can be useful to inform tender documents and budget cycle discussions. Procuring context-appropriate devices  can increase the lifetime of a device and avoid exacerbating “equipment graveyards” . These rThere are also limitations, inherent to data gaps for evidence-based newborn-to-device ratios. These gaps reflect the recent rise of SSNC on the global agenda – the first WHO norms and standards were only published in 2020 . Whilst We assumed a constant unit cost, whilst economies of scale and other cost-saving opportunities might exist, so the costs may be lower than we report. The tool default cost estimates may underestimate costs as the government procurement agencies, whilst mostly consistent across these three African countries, were generally lower than private distributors. Cost differences may be attributable to more stringent device specifications and explicit add-ons  included in private distributor costs. The government procurement agency pricelists do not give minimum specifications for devices. Instead, some provide a list of companies from which health facilities can procure devices . ResearcUse of data to guide budget allocation and catalyse resource mobilisation is crucial in all contexts, but even more so in high-burden settings with relatively low per capita expenditures on health. The review revealed gaps for systematic planning tools notably for devices for small and sick newborn care. Our new tool provides practical evidence-based guidance to countries scaling up care for small sick newborns to accelerate progress toward ENAP and the SDG 3.2 target for neonatal survival. Systematic planning and costing could prevent costly mistakes that can arise from incorrect estimations . To provide high-quality newborn care, the use of appropriate devices, furniture, and fixtures must be coupled with effective implementation including infrastructure, health workforce and data to drive change, reaching every district in every country.Additional file 1. Adapted ISPOR Criteria for Cost(-Effectiveness) Review Outcome (CiCERO) checklist.Additional file 2. Review on planning and costing tools.Additional file 3. Review on type and quantity of neonatal devices.Additional file 4. ABC planning and costing tool for ward furniture and neonatal devices.


Approximately 27% believed COVID-19 was no more serious than seasonal influenza and that they had a low risk of acquiring COVID-19. Nearly 20% disagreed that COVID-19 vaccines in Australia were safe and perceived they were at higher-risk of acquiring COVID infection than the general population. Higher-risk perception viewing vaccination as their professional responsibility, and vaccine mandate strongly predicted vaccination behaviour. Participants consider COVID-19 information from health professionals, government websites, and World Health Organization as the most trusted information sources. The findings highlight that healthcare decision-makers and university administrators need to monitor students’ hesitancy with vaccination to improve students’ promotion of the vaccination to the general population.Using a cross-sectional online survey we investigated knowledge, attitudes, and risk perception about COVID-19 vaccination and identified factors influencing vaccine uptake among Australian health professional students from October 2021 to January 2022. We analysed data from 1114 health professional students from 17 Australian universities. Most participants were enrolled in nursing programs (The online version contains supplementary material available at 10.1057/s41271-023-00422-9. Vaccine mandate appears to be effective in achieving a high rate of COVID-19 vaccination among health professional students.Nearly one in five participants perceived COVID-19 as a low-risk infection.Strategies, such as raising awareness about the pandemic and vaccination, are needed to address vaccine hesitancy among students.As of 14 December 2022, COVID-19 had caused over 7.4 million reported deaths and 18 million estimated deaths , p = 0.013, respectively), because COVID-19 vaccination is an important professional responsibility , and because they held perceptions of higher risk of acquiring COVID-19 infection than the general population (somewhat agreed)  had higher odds of having received vaccination compared to the reference groups.The multivariate logistic regression analyses  did not think finding reliable information about vaccine safety was easy, and 34.3% (n = 326) disagreed that the information from the government about vaccine safety was clear.Participants reported that the three most trusted and used information sources about the COVID-19 pandemic and vaccines were health professionals, government websites, and World Health Organization  were more likely to doubt the seriousness of COVID-19 disease and hold perceptions that they had a lower risk of acquiring COVID-19 infection than the general population. Because young adults (18–29 years) had the lowest hospitalization and death rates among adult age groups [Doubts about the seriousness of COVID-19 disease and the perceived low risk of developing the disease can be barriers to vaccine acceptance  and weree groups , we expeAttitudes toward vaccine safety and effectiveness may have contributed to vaccine hesitancy ; these wWe observed three positive predictors of COVID-19 vaccination uptake including higher-risk perception of acquiring COVID infection than the general population, viewing vaccination as their professional responsibility, and vaccine mandate, with vaccine mandate as the most significant predictor. Notably, in the months prior to data collection the Queensland government mandated COVID-19 vaccination for all health professionals including health professional students. Failure to comply resulted in the termination of employment for health professionals and the withdrawal of placement for health professional students. Thus, the consequence of not following the COVID-19 vaccination mandate was significant, and likely explains why approximately 25% respondents had received vaccination against COVID-19 because of the mandate.The proportion of students who opposed the COVID-19 vaccine mandate varied but was high worldwide, with nearly 30% of participants opposed to the mandatory COVID-19 vaccination policy in our study , 51% in Germany , and 71.Approximately 75% of the participants held views of vaccination as an important professional responsibility, another strong predictor. Consistent with our findings, an Australian qualitative exploration of healthcare workers reported that an expectation of their role was responsibility to receive the vaccine . SimilarAnother strong predictor of vaccination was the perception of a higher risk of acquiring COVID-19 infection than the general population. This is consistent with the fact that risk perception plays a significant role in vaccine uptake, a critical predictor of people’s vaccination behaviour . Nursingn = 326) stated that information from the government about vaccine safety was unclear. Contrary to our findings on commonly used and trusted sources, social media has been reported as the main source of COVID-19 vaccination information in many studies, including a general population study in Cyprus (31.6%) [The three most trusted and used information sources about the COVID-19 pandemic and vaccines in our study were health professionals, government websites, and World Health Organization. Similarly, a cross-sectional study of 2341 students at a diverse, public university in the United States reported government and medical professionals had been the most trusted sources of information . Many st (31.6%) , health  (31.6%) . Althoug (31.6%) , 26, 27, (31.6%) . Governm (31.6%) . This apOur findings represented self-reported perceptions of student who were willing to participate. Students who did not participate might have different attitudes toward vaccine hesitancy, thus we may have underestimated the true prevalence of vaccine uptake among this cohort. We received responses mainly from Queensland in Australia, limiting the generalization of findings to the whole country and other countries. As most participants were nursing students, findings may not represent all health professional students. The findings are representative of a high-income country only, with stringent border controls and no other countries neighbouring its boundaries. We did not ask the participants if they had received one or two doses of the vaccine at the time of the survey. Our survey tool was not validated, and we did not clarify if ‘acquiring’ meant ‘infection’ in one of our survey questions, which may have biased our responses. Despite these limitations, the sample size was large, and we drew the sample from multiple universities, which gives a realistic picture of the topic in Australia. The study findings provide useful insights for governments, policymakers, and university authorities responsible for developing strategies for future vaccine uptake and pandemic management.Our study shows that Australian health professional students had a high vaccination rate. Their concerns persist, however, about COVID-19 infection and disease seriousness and vaccine safety and effectiveness against acquiring infection. This implies a need for healthcare decision-makers and university administrators to invest resources to mitigate vaccine hesitancy and raise awareness about the pandemic and vaccination among university health professional students. The purpose will be to improve their willingness to recommend COVID-19 vaccination to the general population to limit ravages of COVID-19 or other pandemics.Supplementary file1 (DOCX 104 kb)Below is the link to the electronic supplementary material.