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Background  Sustainable Development Goal  ( SDG) aspires to improve universal health coverage through reduction of Out of Pocket Expenditure (OOPE) and improving the quality of care. In the last two decades, there have been several efforts to reduce the OOPE for maternal and newborn care. In this paper, we evaluate the change in the OOPE for treatment of sick newborn at hospital before and after implementation of a free newborn care (FNC) program in hospitals of Nepal.    Methods  Ministry of Health and Population implemented a free newborn care program which reimbursed the cost of treatment for all sick newborns admitted in public hospitals in Nepal from November 2017. We conducted this pre-post quasi-experimental study with four months of pre-implementation and 12 months of post-implementation of the program in 12 hospitals of Nepal. Logistic regression analysis was conducted for categorical variables and Mann-Whitney test was applied for continuous variables to determine statistically significant differences between pre- and post- intervention period.    Results  A total of 353 sick newborns were admitted into these hospitals before implementation of the FNC program while 1122 sick newborns were admitted after the implementation. Before implementation, 17 % of mothers paid for sick newborn care while after implementation 15.3 % mothers ( p -value = 0.59) paid for care. The OOPE for treatment of sick newborn at hospital before implementation was Mean ± SD: US dollar 14.3 + 12.1 and after implementation was Mean ± SD: USD 13.0 ± 9.6 ( p -value = 0.71). There were no significant differences in neonatal morbidity after the implementation of the FNC program. The stay in a hospital bed (in days) decreased after the implementation of FNC program ( p -value < 0.001) while the cost for medicine increased ( p -value = 0.02). The duration of hospital stay (in days) of sick newborns significantly decreased for Hypoxic Ischemic Encephalopathy (HIE) ( p -value = 0.04) and neonatal sepsis ( p -value < 0.001) after the FNC program was implemented.    Conclusions  We found no change in the OOPE for sick newborn care following implementation of the FNC Program. There is a need to revisit the FNC program by the type of morbidity and duration of stay. Further studies will be required to explore the health system adequacy to implement such programs in hospitals of Nepal.    Trial registration  ISRCTN-  30829654 , Registered on May 02, 2017.

Impact of free newborn care service package on out of pocket expenditure‐evidence from a multicentric study in Nepal