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WHO/UNICEF - Joint Statement Service Delivery & Program Implications

Dr. Winnie MwebesaDr. Stella Abwao

CORE Group Fall MeetingSeptember 14-15, 2010

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Service Delivery & Program Implications

Outline• Background

– Rationale – why focus on PNC home visits?

– Evidence– Recommendations

• Malawi country experience

WHO/UNICEF - Joint Statement

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1960 1980 2000 2020Year

Rationale 1: Neonatal deaths & MDG 4

Almost 40% of under 5 deaths are neonatal – 4 million a year

MDG4 can be achieved if neonatal deaths are reduced

Under-5 mortality rate

Late neonatal mortality

Early neonatal mortality

Target for

MDG-4

Source: Lawn JE et al Lancet 2005

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Rationale 2: When do newborn deaths occur?

Up to 50% of neonatal

deaths are in the first 24 hours

75% of neonatal deaths are in

the first week – 3 million deaths

Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)

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Rationale 3: Where do newborn deaths occur?

• 99% of all newborn deaths occur in developing countries

• Most newborn deaths occur at home • 47% of mothers and newborns do not

receive skilled care during delivery (and those who do are sent home early)

• 72% of all babies born outside health facilities do not receive any postnatal care

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Direct causes of 3.72 million neonatal deaths - almost all are due to preventable conditions

Source: Lawn JE, Cousens SN, Zupan J Lancet 2005.

60 to 90% of neonatal deaths are in low birth weight babies, mostly preterm

Rationale 4: What causes newborn deaths?

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Evidence of Home Visits for Newborn Care

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Recommendations: underlying principles

Core principle - continuum of care covering both lifecycle and home-to-hospital (and “back again”)

dimensions

Home visit is a complementary strategy to facility-based postnatal care …. to improve newborn

survival

• Facility births: assess health of mother and baby before discharge and give specific return date

• Non-facility births: Seek postnatal care from a skilled provider (in most places at facility) as soon as possible

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Recommendation: Home Visits

• At least two home visits for all home births:– First visit - within 24hrs of birth– Second visit - day 3– Third visit - day 7 (if possible)

• At least two home visits for all babies born in a health facility:– First visit - soon as possible

when mother returns home– Second visit - day 3– Third visit - day 7 (if possible)NB: At least one home visit during

antenatal period will be required

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Recommendation: content of home visits

• Ensure basic newborn care (or essential newborn care):– Early & exclusive breastfeeding– Maintenance of warmth– Hygienic cord and skin care– Caretaker’s hand washing– Assess for danger signs and refer – Counsel on danger signs and prompt

care seeking – Identification and support for newborns

with conditions that require additional care (e.g. LBW or sick baby, mother is HIV+)

• Mother:– Ask and counsel about danger signs

and prompt care seeking– Counsel on birth spacing and nutrition

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Recommendation: Who should make visits?

Ideally - should be skilled health workers but….

Realistically it is:Existing community health workers (paid

and/or volunteers)

Malawi - Health Surveillance Assistants(HSAs)Indonesia - Community midwives India - Anganwadis and ASHAs Nepal - Female community health volunteersEthiopia - Health Extension Workers (HEWs)Rwanda - Female health worker (ASM)

• Create new CHWs (paid and/or unpaid)

IT IS ESSENTIAL THAT CHWs HAVE KNOWLEDGE AND SKILLS TO

ACCOMPLISH WELL DEFINED TASKS

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Program implementation guidance

• National PNC service delivery situation analysis• Policy dialogue and adoption

– Potential policy changes for CHWs to:• Assess newborns• Coach mothers and families to practice KMC • Provide oral and/or injectable antibiotics• Manage asphyxia with resuscitation equipment

• Adoption of PNC home care delivery strategy where appropriate• Recruit and/or train health workers or CHWs• Ensure continued professional development and motivation• Strengthen health system (logistics, supervision and referral

linkages) to support PNC• Ensure community awareness and engagement in PNC services• Document the process and results especially community-based

management of neonatal sepsis, LBW babies and asphyxia.

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Health system requirements

• Health workers are from and/or live within communities

• Functional linkage of community health workers and facilities (e.g., referral, transport, supervision & monitoring, quality assurance)

• Integration of services delivered by health worker and first-level facility across the continuum– Pregnancy surveillance, antenatal visits & ANC, care

at delivery, early postnatal care, community case management, immunization & nutrition

• Integration with existing programs (eg, Safe Motherhood, IMCI, PMTCT)

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Steps to implement Joint Statement

• Countries should analyze policies, practices, and delivery platforms to identify potential of postnatal home visits to improve newborn survival.

• Prioritize home visits where access to facility-based care is limited, including after discharge for facility births.

• Utilize existing delivery platforms of community health workers and volunteers, ensure linkage of CHWs to health system and quality of referral care,

• Monitor early PNC coverage and quality, key newborn care practices, and health outcome indicators.

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Bangladesh

GoB and BRAC community health workers

ANCC, PNC visits

Pakistan GoP Lady Health Workers

CM, ANCC, PNC; attendance home births (resus, LBW extra care, identify infection and begin antibiotics

Nepal National Neonatal Health Strategy

Female community health volunteers (FCHV)

Indonesia GoI Community Midwives (Bidan di desa)

Bidan di desas (community midwives)

Malawi MOH policy; OR demonstrating “how”

Health Surveillance Assistants

Ethiopia National MOH standards Health Extension Workers

LAC Regional Neonatal Health Strategy; OR demonstrating “how”

Various cadres (CHWs, ANMs)

Saving Newborn Lives: Home Visits Within National Delivery Platforms

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Country Experience

Background:

• Population of ~14 million

• Low resource country (GDP per capita - US$ 290)

• HIV prevalence 12%

• Inadequate numbers of health service providers/skilled birth attendants/low physician density

MALAWI:

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Country Experience

Background cont:

• Maternal mortality ratio - 807/100,000 live births (MICS 2006)

• Neonatal mortality rate - 33 per 1,000 live births (MICS 2006)

• Over 17,000 newborn deaths each year

MALAWI:

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Infection, 30%

Diarrhoea, 2%

Asphyxia, 22%

Congenital, 7%

Preterm, 30%

Other, 6%

Tetanus, 3%

Causes of neonatal death (estimated for 2005)

Source: Lawn JE et al. 2006

Three causes

account for ~84% of neonatal deaths in

Malawi

MALAWI:

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54% 18% 86%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Antenatal care (at least one visit, 4+

visits)

Skilled attendant during childbirth

Postnatal care within 2 days

(births in facility and at home)

Immunisation (DPT3)

Lowest Highest

92%

Coverage of key packages along the continuum of care

Source: MICS 2006

Gap in coverage between poorest and least poor

MALAWI:

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Focus:• Increasing community knowledge and practice of key

maternal and newborn health behaviours and demand for care.

• Improving access, availability and quality of existing facility-based maternal and newborn care services along the household-to-hospital continuum of care, including training (IMNCI) and provision of equipment and supplies.

• Evaluating results of community-based maternal & newborn

care in terms of program cost, feasibility and changes in behaviours and coverage of care.

Community Based Maternal & Newborn Care (CBMNC) Program

MALAWI:

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CBMNC Program

Program is implemented in partnership with: MOH-RHU, CHAM, Save the Children, UNICEF, MCHIP, WHO, Norwegian Church Aid and UNFPA• Started in 2007 - 3 year demonstration

implemented in 3 districts to evaluate the feasibility, cost and outcomes of a CBMNC package

• Scale-up of program interventions underway district-wide and in 4 other districts (7 total)

• In the pipeline - 5 additional districts (12 of 28)

MALAWI:

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CBMNC Program - Milestones

• 2006 - MOH representatives made a learning visit to SEARCH in India (Dr. Abhay Bang). Success of this CBMNH program in Asia influenced and motivated Malawi policy makers

• February 2007 - program design workshop held

• 2008-ongoing - training of HSAs in CBMNC & CM

• 2010 – Malawi government has mandated all partners interested in CMNH to use the CBMNC package

MALAWI:

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CBMNC: Role of Health Surveillance Assistants (HSAs)

• MNH services are promoted through community mobilization and structured home visits by HSAs

• HSAs are trained to: – Facilitate community mobilization – Counsel pregnant and recently delivered

women on importance of attending ANC, birth preparedness, clean delivery, delivery by skilled attendant, ENC, identify mothers and newborns with danger signs and refer

– Make 3 home visits to pregnant women, then to women and newborns within 24 hours, at day 3 and day 8 post-delivery

MALAWI:

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CBMNC - HSA Training

• HSAs undergo a 10-day CBMNC training and 8-day CM training.

• Trainings to date– CBMNC 60 trainers; 1079 HSAs trained– Community Mobilization 66 trainers;

913 HSAs– Other related trainings held on

Kangaroo Mother Care (KMC)

MALAWI:

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CBMNC: Moving to Scale

• MOH-RHU has taken a leadership role– Feb. 2010 mandated all partners implementing

CBMNC to use the integrated national package– July 2010 national dissemination of integrated CBMNC

package to facilitate scale up

• UNICEF contributed to the production of CBMNC training manuals for national use and procured equipment and supplies

• DHO/district and health center teams responsible for supervision

• Media products developed to facilitate dissemination

MALAWI:

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CBMNC: Challenges

Resource constraints• Training pace slower than anticipated • CBMNC scale-up to other districts delayed• Some partners resistant

Logistics• Many HSAs reside outside their catchment areas• No transportation available to facilitate home

visits and supervision• Work overload for HSAs heavily tasked with

community and facility duties

MALAWI:

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CBMNC: Challenges cont

M&E and Supervision• Poor data flow at all levels• Delays in flow of data from peripheral to central level• Some newborn indicators not integrated with the HMIS• No transportation available to facilitate HSA supervision

Health facility services• Overwhelming demand for labour and delivery services at health

facilities• Work overload for midwives and constrained resources at health

facilities• How to maintain quality of services while moving to scale

Cultural issues • Women hide their pregnancies in first trimester for fear of witchcraft,

hence late ANC attendance

MALAWI:

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CBMNC: Lessons Learned

• Need to improve data flow, data use and integration with HMIS

• District Health Offices (DHOs) to aggressively pursue strategies to ensure HSAs reside in their catchment areas

• Successes in implementing CBMNC creates challenges at H/F level leading to congestion accompanying severe understaffing

MALAWI:

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CBMNC: Lessons Learned cont.

• To promote institutionalization of CBMNC– Involvement of government and key partners is

crucial from the start

– Implementation within prevailing structures and staffing structures of the MOH reduces perception of CBMNC as a parallel program

– Key involvement of DHMTs and Zonal Offices in planning, implementation and M&E processes, strengthens ownership and facilitates scale up

MALAWI:

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CBMNC: Conclusions

• Mid-term evaluation of the 3 demonstration districts showed that it is feasible to equip HSAs with knowledge and skills to provide key MNH interventions related to structured home visits. – LQAS showed HSA coverage of home visits: ANC 70%, PNC 60%

• Home visits by CHW have led to improved MNH household care-seeking practices

• Structured CHWs home visits can be adopted and scaled-up to improve MNH services

• CBMNC can move to scale within integrated packages and effective partnerships with efforts directed towards the following: a dedicated CBMNC taskforce; appropriate program design; CHW training; availability of community materials and supplies; implementation support; evaluation of interventions; and costing

MALAWI:

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What Next? Although home visits are underway in several countries, several challenges still exist and work is not completed yet

So……….

What can PVOs, Partners and Programs do to reach the unreached?

Service Delivery & Program Implications

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What Next: Considerations

How can PVOs/Programs help improve/ensure the following?

Training of CHWs Length of trainings and integration into other related basic CHW

training Quality of trainings in the context of district wide/country wide scale

up CHW quality service delivery

• Ensure CHWs focus on community services/home visits • Strengthen supervision and performance reviews of HSAs• Referral and health facility system overload

MNH data - community to district/central levels Data collection, data flow and data use within programs and

integration within HMIS Use of new technology e.g. cell phone

Logistics management and support Supplies and equipment Transportation

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Thank you!

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Group Discussion Session• GRP 1: Discuss and share information regarding current

models for effectively reaching mothers and newborns during pregnancy and postnatal period through home visits. Highlight successes, challenges and gaps

• GRP 2: How can PNC/PPC be incorporated and/or strengthened within current or upcoming programs? Provide program and country examples if possible

• GRP 3: In countries where MNCH national programs exist, what critical role or contributions can PVO and partners make towards scale-up of such PNC/PPC interventions? – Consider needs related to funding, technical

assistance and other support as would be needed