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A Decade of Change

for Newborn Survival

Changing the trajectory of our future

Dr Anthony K Mbonye

Ministry of Health

Overview of the supplement and Uganda analysis

Health Policy and Planning, Supplement 3, 2012

1. Overview of a decade of change supplement Dr Anthony Mbonye, Ministry of Health

2. Changes in newborn health outcomes and coverage indicatorsDr Olive Sentumbwe, World Heath Organization

3. Programmatic and policy changes over the past decadeDr Hanifah Sengendo, Saving Newborn Lives, Save the Children

4. Changing the trajectory for our futureDr Gelasius Mukasa, IBFAN; Newborn Steering Committee

Outline of presentations

Uganda Decade of Change and Future Implications Analysis Group

Allisyn Moran (Saving Newborn Lives Save the Children)

Anthony K Mbonye (Community Health Services Ministry of Health)

Christine Zirabamuzaale (Consultant)

Francine Kimanuka (UNICEF Uganda)

Gelasius K Mukasa (IBFAN)

Geofrey Bisoborwa (WHO Uganda)

Hanifah Naamala Sengendo (Save the Children Uganda)

Imelda Namagembe (AOGU)

Jamil Mugalu (Mulago Hospital)

Janex M Kabarangira (USAID)

Jessica Nsungwa-Sabiiti (Ministry of Health)

Joy E Lawn (Saving Newborn Lives Save the Children)

Kate Kerber (Saving Newborn Lives Save the Children)

Lillian Luwaga (Ministry of Health)

Margaret Nakakeeto (Child Health Advocacy International – Uganda)

Mary Kinney (Saving Newborn Lives Save the Children)

Miriam Mutabazi [Management Sciences for Health (MSH)]

Miriam Sentongo (Reproductive Health Division Ministry of Health)

Nathalie Gamache (Saving Newborn Lives Save the Children)

Olive Sentumbwe-Mugisa (WHO Uganda)

Patrick Aliganyira (Save the Children Uganda)

Peter Waiswa (MUSPH; Karolinska Institutet)

Robinah Kaitiritimba (Uganda National Health Consumers Organization)

Romano Byaruhanga (Nsambya Hospital; AOGU)

Sabrina Kitaka (Uganda Paediatric Association)

Sakina Kiggundu (Uganda Private Midwives Association)

Sarah Kiguli (Makerere University)

Newborn health champions:11 authors

on behalf of 30 person expert working groupRepresenting

government, heath professional

associations, local academia and

research institutions, UN, donor partners, and civil society

To conduct a multi-country evaluation of

progress in reducing neonatal mortality

from 2000 to 2010 examining changes

in context, coverage of care, health

financing, and health systems and

policy, in order to identify pathways to

scale and potential accelerators or

constraints.

Purpose of the analysis and supplement

In some countries, newborns face a more certain future than 10

years ago, yet in other countries very little has changed.

– Darmstadt et al, HPP editorial

Editorial – Gary Darmstadt, David Oot, Joy Lawn

1. Overview and quantitative analysis:- Neonatal mortality rates and causes

- Multi-country regression modelling to understand predictors of change

- Financial analyses

2. Benchmarking readiness for scale up of newborn care

3. Bangladesh

4. Nepal

5. Pakistan

6. Malawi

7. Uganda

Overview of the papers in the supplement

Country case studies with in-country expert teams

Over 150 contributors globally

39,000 newborn deaths in 2010

• High and stagnant total fertility rate

• Most women access antenatal care and bring their children for immunisations

• Institutional births are increasing: 39% in 2001 to 57% in 2010)

• Gap in access and quality of care between the richest and poorest families

• Human resource for health crisis: health worker density of 14.3 per 10,000 population (2005) compared to WHO benchmark of 23 per 10,000 population.

• History of regional civil unrest and IDP/refugees

Uganda at a glance

Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117.

• Neonatal, under-five and 1-59 months mortality

change from 1990-2010 and comparison to other

countries in the region

• Changes in coverage levels from household

surveys at national and sub-national levels

• Changes in quality of care from health facility

assessments and HMIS data

• Changes in financial inputs from government and

official development assistance and comparison to

Countdown to 2015 countries

Quantitative data analyses conducted


• Changes in national socio-political and

economic context

• Progress in achieving 27 sentinal benchmarks

reflecting readiness to scale up newborn care

interventions

• Inclusion of newborn survival specifically and

in general in national health policies,

programmes, and research activities using a

policy and programme timeline

Policy and programme change analyses


Source: Mbonye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Note: The missing

benchmark relates to financial commitments and does not have data.

Progress towards Scale-up Readiness

Benchmarks for newborn care

A Decade of Change

for Newborn Survival


Dr Olive Sentumbwe

WHO

Quantitative data findings for the Uganda analysis


National progress towards Millennium Development

Goal 4 for newborn and child survival from 1990


Data sources: Uganda Demographic Health Surveys. UN estimates of neonatal and under-five mortality (UNICEF et al. 2011) with a new analysis of mortality trends by age of

death. IHME estimates (Lozano et al. 2011). Note: Survey point estimates are centred two years prior to survey date. MDG 4 target from Countdown to 2015 decade report

reflecting a 2/3 reduction from 1990 U5MR.

99

58

26

0

20

40

60

80

100

120

140

160

180

200

1990 1995 2000 2005 2010 2015

Mo

rtality

per

1000 liv

e b

irth

s

Year

Under-five mortality rate (UN)

Under-five mortality rate (IHME)

Under-five mortality rate (DHS)

Neonatal mortality rate (UN)

Neonatal mortality rate (IHME)

Neonatal mortality rate (DHS)

MDG 4 target

Mortality for children aged 1-59 months reduced at nearly twice the

rate of newborn mortality (4.1% vs 2.2%)

Neonatal mortality trends from 1990

Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data sources:

Uganda Demographic and Health Surveys.. UN estimates (UNICEF et al. 2011a). IHME estimates (Lozano et al. 2011). Note: Survey point estimates are centred two years prior

to survey date.

Newborn mortality in Uganda is reducing at 2.2% per year, slightly

more than the regional average for Africa at 1.5%

Understanding neonatal mortality change, 2000-2010

144 countries, multiple regression modeling

Developed region3% reduction per year

Consistently rapid

neonatal mortality

reduction across countries

Strongest predictors of

NMR change

- Increased national

income

- Reduced fertility

Other regions(including Southern Asia)

3.2% reduction per year

Variable change in mortality

reduction across countries

Strongest predictors of

NMR change

- Reduced fertility

- Baseline level of

neonatal mortalitySub-Saharan Africa

1.5% reduction per year

Mortality reduction is slow and therefore difficult

to analyze what factors related to change.

Source: Lawn J,E. et al. 2012. Newborn survival: a multi-country analysis of a decade of change. Health Policy and Planning. 27(Suppl. 3): iii6-ii28.

Countries with increased contraceptive use have made more progress in reducing newborn deaths

Mortality reduction progress could not be attributed to changes in coverage due to limited coverage change and lack of coverage data.

Estimated causes of mortality in 2010

for 39,000 newborn deaths


Data source: Uganda-specific mortality estimates (Liu et al. 2012). Note: Severe infections include sepsis, meningitis, pneumonia and tetanus.

3 causes

account for 90%

of all newborn

deaths

Trends in coverage data for newborn-related interventions and packages

Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data sources:

Uganda Demographic and Health Surveys.

0% 20% 40% 60% 80% 100%

Exclusive breastfeeding (0-1 month)

Case management for pneumonia (0-6 months)

Postnatal care within 2 days (home births)

Breastfeeding initiated within 1 hour

Babies weighed at birth

Deliveries by caesarean section

Skilled birth attendance

Last birth protected against tetanus

Intermittent preventive treatment in pregnancy…

Antenatal care (4 or more visits)

Antenatal care (1 or more visits)

Contraceptive prevalence rate (any modern…

Percent coverage

UDHS 2001

UDHS 2006

UDHS 2011(preliminary)

Despite increases in coverage of some interventions many indicators

remain low, eg contraceptive use, PNC

17% point increase

Increases in coverage of skilled attendant at birth

12 11

18

56

39

27

3639

71

59

0

10

20

30

40

50

60

70

80

90

100

Bangladesh Nepal Pakistan Malawi Uganda

Co

vera

ge (

%)

Around the year 2000

Around the year 2010

Source: Lawn J,E. et al. 2012. A decade of change for newborn survival, policy and programmes (2000–2010): A multi-country evaluation of progress towards scale. Health Policy and Planning. 27(Suppl. 3).

Over half of women deliver with a skilled attendant in Uganda – an increase from 2000

Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data source:

Analysis of World Health Organization National Health Accounts (WHO 2011b). Note: all values in constant 2008 USD.

Total health expenditure by government, out-

of-pocket, and other private expenditure

Funding for health and MNCH has increased but

direct spending by families remains the bulk of health financing

Majority

is out-

of-

pocket

Source: Mboye et al. 2012. Newborn Survival in Uganda: a decade of change and future implications. Health Policy and Planning 27(Suppl. 3): iii104-iii117. Data source: (Pitt

et al. 2010) with special analysis done by C. PittNote: All values are in constant 2008 USD.

0

20

40

60

80

100

120

140

160

180

200

2003 2004 2005 2006 2007 2008

US

$ m

illi

on

s

Year

ODA for child health with no reference to

'newborn' (US$ millions)

ODA for MNCH with reference to 'newborn'

(US$ millions)

ODA for maternal and newborn health with

no reference to 'newborn' (US$ millions)

Changes in official development assistance for MNCH

Child health donor

projects with no

reference to newborn

terms in the search

fields

Maternal health

donor projects with

no reference to

newborn terms in the

search fields

MNCH donor projects

with reference to

newborn terms in the

search fields

A Decade of Change for

Newborn Survival


Dr Hanifah Naamala Sengendo

Saving Newborn Lives, Save the Children

Policy and Programme Change




0 3 6 9 12 15 18 21 24 27

2010

2005

2000

Number of benchmarks

Achieved Partially achieved Not achieved Missing







Formative

research

HBB, KMC,

VHT training

Timeline of progress

When was policy and programme change achieved?

Two pivotal milestones for newborn survival involving multiple champions,

partners and wide ownership

Advocacy, partnerships and convening

mechanisms

PakistanInformal advocacy by civil

society, academia, and donors

became formal in 2008 with

Advocacy and Advisory Network

for Newborns (AANN)

Bangladesh Informal partnerships led by MoH with collaboration

from high profile newborn health

champions

Uganda Formal convening mechanism through the

Newborn Steering Committee

within MoH Maternal & Child

Health cluster

How was policy and programme change achieved?

A Decade of Change for

Newborn Survival


Dr Gelasius Mukasa

Executive Director, IBFAN Uganda

Chairman, National Newborn Steering Committee

Current gaps and future plans for newborn health and survival


• Neonatal mortality reduced by 20% in the past

decade, more than the regional average but not

enough to help meet MDG 4 for child survival

• Recent attention for newborn survival has lead to

rapid change in policies and programmes but

coverage increases arising from these changes have

yet to be seen

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Key messages from the Uganda analysis

• Local evidence and experience has been invaluable towards ensuring newborn health is prioritised across the health sector

• The Newborn Steering Committee has led in change and strengthened dialogue among the MNCH community – is it sustainable and what are the next steps?

Key messages from the Uganda analysis

Together we have the tools, funding and opportunity to transform

maternal, neonatal and child survival in Uganda– will we deliver?

• Link family planning programmes to maternal and newborn survival

• Integration with HIV/AIDS messages and programmes especially around PMTCT delivery

• Continued partnership with health professionals: AOGU, UPA, UPMA, etc

• Finding and developing multi- sectoral champions: education,

finance, planning, parliamentarians

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Outstanding gaps in programme integration

• Strategically include the private health sector as many people access the health services from it i.e. about 40% of health services in Uganda are offered by the private sector

• Business community not yet incorporated yet it can play a vital role, especially through corporate social responsibility

• Attention of social marketing groups / marketeers not yet drawn

Outstanding gaps in programme integration

• Methods for further increasing facility delivery and quality

of care at health facilities

• Capacity of VHTs to identify and refer sick newborns in

the context of iCCM

• Length and content of newborn care training package

• How to cover LSS, HBB, KMC, IMNCI, MPDR, etc

• H/Ws are very knowledgeable, however, their practical

skills are limited (seen from the pretests conducted).

There is urgent need to equip them with practical skills so

as to match their level of knowledge

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Outstanding gaps in evidence

Through an external evaluation, it was realized that:

The Steering Committee is operating at the central / national level

As a way forward:

1. Incorporate representatives from various districts onto the

central committee

2. Establish newborn district teams to enhance ownership at

district level and communication through district representatives

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Plans for the National Steering Committee

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Summary Fact cards and additional information at the

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http://www.healthynewbornnetwork.org/resource/decade-change-

newborn-survival-summary-cards

Additional materials, resources, powerpoints:

http://www.healthynewbornnetwork.org/page/decade-change-

newborn-survival

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