The annual health system cost of operating SNCU at the district level is INR 6.3 million. The average cost of treatment per neonate is INR 4581, while per bed-day treatment is INR 818, as reported from a study of four SNCUs [2]. However, there needs to be a careful cost estimation before generalization, as both the capital and recurrent cost will vary according to Gross Domestic State Product of states. The analysis suggests that the overall costs of neonatal intensive care for all those who require level II care would be around INR 20.4 billion. This comprises 0.8% of India’s health care spending [2]. While cost has important implications at the national level, its effectiveness on the outcome of admission emerges as the key indicator to promote SNCUs at the district level. To improve the cost effectiveness, the outcome of admissions needs to be analyzed. The outcome depends heavily on the input costs and profile of babies admitted [3]. The bulk of admissions in India are because of birth asphyxia, low birth weight and sepsis. Birth asphyxia can very well be prevented by strengthening Newborn Care Corners (NBCC) at every delivery point. Regionalization of neonatal care is known to be an effective way to reduce costs and improve effectiveness [4]. Unfortunately, in India, the emphasis on setting up of SNCUs at district level has not been translated into development of an integrated system of facility based newborn care [5]. Strengthening of an integrated model with SNCU at the district hospital and having a good linkage with Neonatal Stabilization Units (NSU) at 24x7 Primary Health centers and Community Health centresand NBCCs at each delivery point has not been accorded an importance.

As the definition of a viable fetus has been changed to include babies with lower gestational age, the cost of care of such neonates has increased drastically [6]. But in a situation where most of the neonates admitted to SNCUs have normal birth weight, these vulnerable newborns are likely to suffer the most. Laxity of admission and discharge criteria resulting in over admissions and high bed occupancy rates often results in lack of attention and care of this category of neonates [2,5]. This may affect the performance of such units in an adverse way.

Acknowledgment: The author acknowledges the contribution of Mr. Maulik Chokshi and Prof Sanjay Zodpey (IIPHS) towards finalization of the draft.

Competing interest: None stated; Funding: Nil.

1. UNICEF. Setting up a special care newborn unit in a district hospital. In: Toolkit for setting up of special care newborn units, stabilization units and newborn corners. New Delhi: UNICEF, 2008. p. 29. Available from: http://www.unicef. org/india/SCNU_book1_April_6.pdf. Accessed on 20 August 2009.

2. Prinja S, Manchada N, Mohan P, Gupta G, Sethy G, Sen A, et al. Cost of neonatal intensive care delivered through district level public hospitals in India. Indian Pediatr. 2013;50:839-46.

3. Schmitt SK, Sneed L, Phibbs CS. Costs of newborn care in California: a population-based study. Pediatrics. 2006;117:154-60.

4. Narang A, Kiran PS, Kumar P. Cost of neonatal intensive care in a tertiary care centre. Indian Pediatr. 2005;42: 989-97.

5. Neogi S, Malhotra S, Zodpey S, Mohan P. Challenges in scaling up of Special Care Newborn Units- Lessons from India. Indian Pediatr. 2011;48:931-5.