(WP)/CHD/ICP/CHD/3.1I001-A
Report series number: RS/2005IGElI6(PHL)
English only
REPORT TECHNICAL CONSULTATION ON THE CHILD SURVIVAL STRATEGY
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC and UNITED NATIONS CHILDREN'S FUND REGIONAL OFFICE FOR EAST ASIA AND THE PACIFIC Manila, Philippines 10 to 12 May 2005
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NOTE The views expressed in this report are those of the participants in the Technical Consultation on the Child Survival Strategy and do not necessarily reflect the policies of the World Health Organization or the United Nations Children's Fund.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Technical Consultation on the Child Survival Strategy, which was held in Manila, the Philippines from 10 to 12 May 2005.
CONTENTS
SUMMARy ........................................ ·.······· ....................................... . 1. INTRODUCTION ......................................................................... ,.
1 1 2 2 2 3 3 3 8 9 9 10 11
1.1 1.2 1.3 1.4
Background ................ . . . . . . . . .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Objectives................................................................... ....... ... Participants.......................................................................... .... Opening remarks .....................................................................
2. PROCEEDINGS ........................................................................... ,. 2.1 2.2 2.3 Objective 1: Objective 2: Objective 3: Review and discuss past experiences of child survival and lessons learnt............................. Review and make recommendations on the draft Regional Child Survival Strategy.......... ........... Discuss and plan approaches to scaling up child survival actions ............. .................................
3. CONCLUSIONS............................................................................ 3.1 3.2 3.3 Review and discuss past experiences of child survival and lessons learnt............................. Review and make recommendations on Objective 2: the draft Regional Child Survival Strategy ..................... Objective 3 : Discuss and plan approaches to scaling up child survival actions............. ................................. Objective 1:
ANNEXES: ANNEX 1
LIST OF TEMPORARY ADVISERS, RESOURCE PERSON, REPRESENTATIVES/OBSERVERS AND SECRETARIAT PROVISIONAL TIMETABLE PRESENTATIONS MADE ON 10 MAY 2005 PRESENTATIONS MADE ON 11 MAY 2005 GROUP WORK FOR OBJECTNE 2 PRESENTATIONS MADE ON 12 MAY 2005
ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6
i SUMMARY The World Health Organization Regional Office for the Western Pacific and the United Nations Children's Fund Regional Office for East Asia and the Pacific have corne together in developing a draft Regional Child Survival Strategy document that addresses the recognized gaps in the drive to scale up child survival in the Region. The strategy signifies a strong WHO and UNICEF collaboration and a united approach to achieving Millennium Development Goal (MDG) 4 in the Region. The technical consultation on the Child Survival Strategy was necessary to bring together inputs from experts in the field, including technical experts from Member States, UNICEF, WHO Headquarters, WHO country and regional offices, and other stakeholders, to ensure that the outcome was a technically sound, precise document. This document will be shared with Member States for their review to reach consensus on scaling up child survival actions in the Region. The meeting achieved the three objectives that were set for the three-day consultation: (1) to review and discuss past experiences of programmes and strategies for child survival existing in selected countries of the Western Pacific Region, including lessons learnt; (2) to review and make recommendations on the draft Regional Child Survival Strategy document, including regional targets; and (3) to discuss and plan approaches to scaling up child survival actions through resource mobilization and enhanced coordination with collaborating partners. The consultation brought together 46 attendees: 1 resource person, 17 temporary advisers, 2 observers, and a large secretariat composed of staff members of both WHO and UNICEF. The proceedings of the meeting included presentations, plenary discussions, group work and participatory exercises. Consensus was achieved on the majority of issues, with only a few issues being referred back to the secretariat. Conclusions are summarized below. For objective 1, the meeting concluded that child survival interventions have good evidence of efficacy and that the global community has failed children by not allocating sufficient resources to applying those interventions on a sufficient scale. For objective 2, the meeting concluded in relation to: Goal and objectives: The strategy could request countries to set their own targets within the objectives, linking to MDG4. The goal and objectives were generally agreed as reworded on day 2. Categorizing countries: The categorization of countries was agreed upon. It can also be applied within countries, such as China. Document usage, language and format: The Regional Strategy should be brief, clear, visionary and oriented towards advocacy. It should: • include an essential package of interventions; • include complementary interventions and interventions that address underlying causes; • be measured, with a commitment to equity; • aim for universal coverage with the essential package; and • include direction on organizing and mobilizing implementation in countries.
ii Equity: Equity should be the chief priority in planning, implementation and monitoring. There was a general agreement on inclusive coverage of the poorest, with particular actions to achieve this. Integration and ruCI: There should be no conflict between ruCI and the Regional Strategy and the need for integration at every level should be highlighted. The essential package: This should include seven items, roughly corresponding to: • skilled attendance during pregnancy, delivery and immediate post partum; • care of the newborn infant; • promotion of breast-feeding and complementary feeding; • micronutrient supplementation; • immunization of children and mothers; • integrated case management of diarrhoea, pneumonia and malaria; and • insecticide-treated bednets. Birth spacing and related issues as part of the essential package: Good cooperation between maternal, reproductive health and family planning is essential. If birth spacing and prevention of mother-to-child transmission (PMTCT) are not included in the essential package, they must be strongly highlighted in the section previously called 'The Enabling Envirorrment'. Other elements: Further issues concerning nutrition and referral care were referred to the secretariat for consideration. Enabling envirorrmentlComplementary interventions: The meeting did not achieve consensus on the title, referring this to the secretariat. This section should focus on: birth spacing, water and sanitation, PMTCT, and women's education, empowennent and equity. Policy environment, planning and resources: Structuring this section, as part of the way forward, would be most helpful. It could match the framework of the three 'Ones' and the two 'Ms' (see later). Community actions: The community should feature heavily, particularly in the discussion of opportunities for delivery of the essential package. Indicators and monitoring: Equity measures should be included in monitoring. The final list of indicators presented on day three was referred to the secretariat. For objective 3, the meeting agreed, through a participatory planning exercise, on an approach to scaling up the need for: • one coordination mechanism; • one plan; • one monitoring and evaluation system; • mobilizing for advocacy and communication; and • mobilizing resources to accelerate and sustain child survival. The meeting concluded with thanks to all participants for their contributions and work towards improving child survival in the Region. The secretariat was tasked with finalization of the draft Regional Child Survival Strategy for presentation at the 56 th Session of the WHO Regional Committee for the Western Pacific in September 2005.
1
1. INTRODUCTION
1.1
Background
Countries of the Region are committed to the Millennium Development Goals (MDG)' and to reducing child mortality. MDG 4 calls for a two-thirds reduction in the under-five mortality rate between 1990 and 2015. This goal is contingent on all other MDGs, but particularly goals I and 5. Integrated management of childhood illness (IMCI) is an evidence-based primary health care strategy for child health that has been implemented in the Region with the aim of reducing child mortality. IMCI is an effective tool for child survival, but rapid progress towards national coverage has been difficult because of the strategy's low visibility; difficulties in coordination, caused by diverse organizational interests; and a lack of financial investment for rapid scaling up. These issues must be addressed through a comprehensive child survival approach that includes, not only IMCI, but also other strategies to improve the survival of children under five years of age. Child survival is one ofthe priority health issues in the WHO Western Pacific Region and regional statistics show that approximately 3000 children under five die every day. Among those, more than 800 babies die within the first day of life due to complications of pregnancy and childbirth, and more than 1500 deaths occur due to common preventable and treatable conditions, such as diarrhoea, pneumonia, malaria, measles, dengue haemorrhagic fever and undernutrition. There is an increasing burden associated with high child mortality and morbidity, but resources spent on child survival interventions do not always match the burden of disease among children. Child health programme managers attending the regional workshop on IMCI (August 2003) concluded that there was a need to reshape child survival approaches towards stronger outcome orientation, advocacy and monitoring in a way that addresses the existing human and financial resources and health system limitations that currently prevent optimizing delivery of life-saving interventions. The Regional Committee for the Western Pacific at its 541h Session (September 2003) adopted resolution WPR/RC54.R9 on child health, which urges Member States, in particular those with high child mortality, to place child health higher on their political, economic and health agendas, targeting child survival interventions and increasing allocation of financial resources to reduce child mortality and morbidity, especially in countries and areas at greatest need. Following this, the WHO Regional Office for the Western Pacific began developing an outcome-oriented Regional Child Survival Strategy and, in early 2005, joined with the UNICEF Regional Office for East Asia and the Pacific in developing a joint Regional Child Survival Strategy, which addresses the recognized gaps in the drive to increasing child survival in the Region. This strategy signifies a strong WHO and UNICEF collaboration and a united approach to achieving MDG4 in the Region. WHO and UNICEF would also like to see the engagement of other partners in this call for coordinated efforts and resource mobilization in the renewed drive for child survival. 1 UN Millennium Summit: Goals of the Millennium Declaration. September 2000
2 There has been extensive consultation on the draft strategy in the regional and country offices of WHO and UNICEF and with the Child and Adolescent Health Department (CAR) of WHO Headquarters. As part of the consultation process prior to its finalization, a Regional Consultation on the Child Survival Strategy was necessary, bringing together inputs from experts from the field, including technical experts from Member States and other stakeholders, to ensure that the end result is a technically sound, precise document. The document will be shared with Member States for their review to reach consensus on scaling up child survival actions in the Region. 1.2 Objectives The objectives of the consultation were: (1)
to review and discuss past experiences of programmes and strategies for child survival existing in selected countries of the Western Pacific Region, including lessons learnt; to review and make recommendations on the draft Regional Child Survival Strategy document, including regional targets; and to discuss and plan approaches to scaling up child survival actions through resource mobilization and enhanced coordination with collaborating partners.
(2) (3) 1.3
Participants
The consultation brought together 46 attendees: 1 resource person, 17 temporary advisers, 2 observers, and 26 secretariat members. Eighteen WHO staff from headquarters, regional and country levels, and eight UNICEF officers representing both regional and country levels served as the secretariat. The detailed list of participants is attached as Annex L 1.4 Opening remarks
The opening remarks were delivered by the Regional Director of the UNICEF Regional Office for East Asia and the Pacific, Ms Anuparna Rao Singh and the Director, Programme Management, WHO Western Pacific Regional Office, Dr Richard Nesbit. Ms Singh reinforced that both UNICEF and WHO were committed to MDG 4 and that recent regional events called for countries to place child health higher on their political, economic and health agendas and to increase the allocation of financial resources to reduce child mortality and morbidity. She highlighted the commitment of UNICEF and WHO offices in the development of the joint strategy and called for engagement of other partners. She said there was a great need to deviate from a business-as-usual approach. She identified that the strength of the strategy was that its approach was one of promoting an essential package for child survival together with improvements in the policy environment. Dr Nesbit acknowledged Ms Singh's remarks and the importance of the joint WHOIUNICEF child survival strategy. However, he stated that developing a strategy and having it endorsed by Member States was only the first step in the process. He said that the strategy should be used as a new avenue to harmonize child survival activities in the Region in one
3 direction. He reinforced the importance of !MCI as an important child survival strategy in the Region and said that we should learn from our colleagues in the field of HNIAIDS and try to replicate the three 'Ones': one national Government coordinating structure for child health; one national plan which is locally appropriate; and one monitoring and evaluation framework using agreed core indicators. Lastly, he highlighted that scaling up child survival activities and strengthening health systems would require considerable additional funding. Countries must allocate more and the international community must also mobilize more resources to child survival. The objectives and the agenda were adopted and the office bearers nominated and accepted. Dr Narimah Awin served as Chairperson, Dr Somchit Akkhavong as Vice-Chairperson and Dr Christopher Morgan as Rapporteur. 2. PROCEEDINGS The timetable of the consultation is provided in Annex 2. 2.1 Objective I: Review and discuss past experiences of child survival and lessons learnt
Past experiences of child survival and lessons learnt were presented by Dr Cesar Victora from the Universidade Federal de Pelotas and Dr Elizabeth Mason, CAH Director, WHO Headquarters. Country experiences: gains in child health - lessons learnt in Malaysia, Viet Nam and Mongolia were presented by Dato' Dr Narimah Awin, Dr Dinh Thi Phuong Hoa and Dr Gochoo Soyolgerel, respectively. The presentations are provided in Annex 3. 2.1.1 Issues discussed
Political will is seen as a crucial factor in Malaysia, Mongolia, Viet Nam and other places with demonstrable change. Therefore it will be important to use the strategy to strengthen political will. The strategy requires a better problem statement, especially around sufficiency of human and financial resources, including both those from countries and donors. 2.2 Objective 2: Review and make recommendations on the draft Regional Child Survival Strategy
Dr Linda Milan, Director, Division of Building Healthy Communities and Populations, WHO Regional Office for the Western Pacific, presented highlights of the WHO/UNICEF Regional Child Survival Strategy and Dr Victora presented the evidence for child survival interventions, including evidence of the effectiveness and efficacy of IMCI in improving quality of care and reducing stunting and mortality, from the Multi-country Evaluation of IMCI Effectiveness, Cost and Impact (MCE). The essential package for child survival was presented by Dr Stephen Atwood, Regional Advisor, Health and Nutrition UNICEF Regional Office for East Asia and the Pacific, and the implementation in three target areas by Dr Graham Harrison, Regional Adviser in Health Systems Development, Division of Health Sector Development, WHO Regional Office for the Western Pacific.
4 All presentations for objective 2 are documented in Annex 4. Group work was then conducted for technical review of the Regional Child Survival Strategy. The three groups were each tasked with addressing one of three questions and participants self-selected the group to which they wished to belong. Each group comprised an equal number of participants and one WHO and one UNICEF facilitator. Each group nominated one moderator and one rapporteur. Ouestions for the groups Group 1: In reviewing the document, does the technical content (essential package and the enabling environment) adequately address the major child survival issues in the Region? Group 2: The three target areas - policy environment, service delivery, and family and communities - form a substantial basis for implementation of this strategy. Does the strategy address the most important issues in each of these target areas? Are the suggestions feasible? Group 3: Equity and diversity are major issues in this Region. Does the strategy adequately deal with diversity across different countries in the Region? How could the strategy be better in addressing equity? The reports of each group are in Annex 5 and the main points are described in the relevant sections below. 2.2.1 Goal and objectives
Goals and objectives should be oriented to MDG4 and should indicate a similar time period. Other possibilities raised were strengthening the equity aspect of the goal and adding targets to objectives. It was suggested that the strategy could request countries to set their own targets within MDG4. The use of the term 'accelerated' may help to add urgency and clarify relationships with existing national programmes. 2.2.2 Categorizing countries
The rationale for categorizing countries was presented by Dr Koenraad Vanormelingen, Chief, Health and Nutrition, UNICEF China Country Office, and the categorization of countries was agreed. It could also be applied within countries, such as China. 2.2.3 Document usage, language and format
It will also be important to use the strategy with donors to increase commitment to MDG4. Thus it needs to be targeted, not only towards governments but also donors, including bilateral partners and nongovernmental organizations. To be used with these audiences, it needs to be clear and visionary. Separate summaries or policy briefs from the strategy directed at policy, technical and advocacy audiences, including government, could aid this. There is a need to balance prescription with respect to countries' own plans. There was also a suggestion for separate document tracks that address external agencies and national entities. A single strategy should not obstruct national and subnational adaptation. A significant issue is to ensure that the strategy clearly articulates how it fits with existing activities. It is not a replacement and not a parallel process.
5 The 'interventions', 'delivery mechanisms' and 'adaptation to local situations' should be kept distinct. Good guidance on delivery systems at some point will be important because they detennine the effectiveness of interventions. Additional points: • • • 2.2.4 Targeting - use ofthe term needs to be regularized as it is used in different ways. The table on page 21 should be removed. Different uses of the term 'essential' needs harmonizing. Equity
The equity section in Chapter 8 requires strengthening and inclusion of guidance on monitoring equity. The differential approach for country groupings - universal coverage of the essential package for group one, geographic targeting for group two, and socioeconomic targeting for group three - was discussed. Use of the term 'targeting' versus 'universal coverage' was discussed. Universal coverage may be unclear (recalling EPI definitions) and needs clarification. There is a risk with a package approach that mediocre coverage means less equity than an unpackaged approach because of the 'all-or-nothing' phenomenon. Equity in implementation requires an equity approach to monitoring, noting that this will take time for governments to accommodate. 2.2.5 Integration and !MCI
There was discussion on the degree to which WCI could be highlighted and supported more strongly in the Regional Strategy, with related discussions mentioning the integrated early childhood development (IECD) strategy. Without this there is a risk of losing the connection to the evidence-supported need for integration in delivery mechanisms. There was also concern that the essential package, as it currently reads, will present to policy-makers as if it is a move away from !MCI and back towards vertical programmes, and this may prove confusing for both governments and donors. Experiences from countries: • • WCI has only just started in Papua New Guinea, so more time is needed. !MCI has achieved high coverage in health facilities in Mongolia at a time when stunting and mortality have declined. Mongolia cannot return to vertical systems. Cambodia was not involved in the formal evaluations of the MCE because coverage had not increased sufficiently at that time. Since then, there have been no major surveys, but local surveys and implementation data do suggest increased utilization of services, increased preventive care and lower mortality in WCI districts.
•
WCI has a health system strengthening component but broader health system strengthening is what is needed. It is important to have integration at case management level and health system level both for efficiency and as a response to identif'ying co-morbidity. Part of the need for packaging is the need for integrated care. Integration and delivery mechanisms such as WCI could be highlighted further in both advocacy and technical sections of the document.
6 Integration is both the 'what' and the 'how' of the process. Co-coverage analyses may provide a means to measure integration. 2.2.6 The essential package
The package needs to be as brief as possible for clarity and feasibility. In order to retain flexibility, this is not the place to describe the essential elements of antenatal care, child-care etc. There is a belief that every element can be carried out by every government in the Region. It is, in fact, a minimum package. An expanded and more specific intervention list was proposed on the last day, but discussion suggested that it conflicted with the earlier list, and provided both too much and too little detail for a strategic document. It could be more useful as a technical briefing or supplementary paper. Another concern was that there is insufficient detail on vaccines and there was also discussion around the place of kangaroo mother care and micronutrients. It was clear that this level of detail generates debate rather than consensus and is not appropriate for this level of document. 2.2.7 Birth spacing and related issues as part of the essential package
There was considerable discussion on the role of birth spacing and prevention of motherto-child transmission (PMTCT) in the essential package, with many advocating for their inclusion for both effectiveness and programmatic reasons. PMTCT receives a high level of programme support through HN initiatives and should not be neglected. Related issues discussed included prevention of adolescent pregnancy, pre-pregnancy care and maternal nutrition. Women's education is the core evidence-based component within gender equality and women's empowerment. 2.2.8 Other elements
Nutrition is crucial and may not be highlighted sufficiently in the original draft, for example, the nutrition overlay has been lost from the mortality cause pie chart. Some suggested that assessment and treatment of malnutrition could be part of the package. The detailed sections of the strategy could also expand the important role of the referral care system, especially for pneumonia and malnutrition. 2.2.9 Enabling environment/Complementary interventions
There was discussion on the fact that this section needs to receive the same level of advocacy support as the essential package. The tenninology could be changed to refer to complementary interventions or interventions that address underlying causes of mortality. It is important to ensure non-health linkages are highlighted, possibly including integration with education initiatives, noting that other MDG initiatives will push harder on these areas. 2.2.10 Policy environment, planning and resources
Donors forming a regional alliance for child survival may be able to help with monitoring and other support. One crucial issue is resource allocation, especially human and financial: these are specific parts of past experience that can be applied to future strategic planning. In the
7 meantime, the question was raised as to whether WHOfUNICEF could look at their budgets to support, in particular, the monitoring activities. Human resource issues are crucial, including the role of doctors and professional societies. Their role as both a constraint and an opportunity needs to be understood. Refonnulation of this section around an 'organize and mobilize' fonnat was discussed. Cost is a core issue for countries and donors, but it is also important for communities, remembering that willingness to pay does not correlate with ability to pay. Private sector issues need to be considered in section 11, along with health sector reform and decentralization. One practical application of decentralization can be to harness it to leverage community and local political support. Securing resources to sustain essential interventions is the core issue in group 2 countries. 2.2.11 Community actions
The strategy represents an unusual but welcome emphasis on community empowennent, which is essential for child survival. Community-level interventions are essential to highlight, for example, breast-feeding promotion in Viet Nam. The same issues are likely to constrain community-based treatment of pneumonia as have constrained the !MCI scale up. 2.2.12 Indicators and monitoring
There was discussion in this area on all three days. The core indicators on page 28 of the draft strategy are very important because they are linked to interventions and highlight community interaction. This will be a crucial advocacy tool and should be highlighted, and possibly brought forward in the document or in summaries. A crucial aspect of advocacy is showing benefit, and the core indicators on page 12 are needed for this. More work needs to be done to ensure the indicators match the strategy objectives, especially in the lack of means to monitor equity within countries. Equity monitoring does require repeated large surveys - possibly three surveys between now and 2015. It is important to be aware of the bias of health-facility-based infonnation, but there is the possibility of adding small numbers of questions to activities with high coverage (e.g. questions about breast-feeding). Equity stratification can be by geographic, ethnic, gender and economic status. The last is difficult, but one standard way is the asset index (principal components analysis).
It may be important to harmonize with routine national health information systems, but every country will still need regular surveys. Routine information is mainly limited to geographical disaggregation, but both geographical and socioeconomic disaggregation is required. Adding equity elements could add to the cost of national health infonnation systems and may not adequately measure socioeconomic status. Pacific island countries are already carrying out censuses every five years or so, and use of geographic infonnation systems (GIS) is emerging. It would be difficult to include all 10 core child survival indicators in censuses. Resources for monitoring are required. For example, surveys in the Lao People's Democratic Republic, and many other places, are dependent on donor funds. Mongolia, when conducting mixed survey similar to Multi-Indicator Cluster Survey (MICS) in 1998, noted this was expensive because of distances. The plan is for five-yearly repeats. Viet Nam has surveys including cost-of-living indices. National surveys are important, but it is especially hard to
8 convince the Ministry in Papua New Guinea, although currently nutrition and EPI surveys are planned. Surveys should be a valid area for donor support.
2.3
Objective 3: Discuss and plan approaches to scaling up child survival actions
Monitoring and evaluation was presented by Dr Victora and approaches to improving child survival actions by Dr Robert Scherpbier, Medical Officer, Child and Adolescent Health and Development, WHO Headquarters. A preliminary list of revised indicators was also presented. It still needs to be harmonized with MICS Demographic and Health Survey wording. Some possible additional indicators may address assessing care of the newborn child, initiation of breast-feeding, and utilization of insecticide-treated bednets. There was further discussion on indicators, particularly on harmonizing them with existing systems. Presentations can be found in Annex 6. A 'visualization in participatory programmes' exercise was conducted. Working alone initially, participants were asked to write on coloured cards points relevant to the five headings of the three 'Ones', plus the two 'Ms' shown below. These were then pasted on wall-charts. At the end of the session, participant volunteers arranged the cards under relevant 'themes' within each title given. The points were then ordered so that the sequence of events required to ensure the tasks were completed was shown. One participant then provided feedback on each area in plenary. The main points of each group's feedback are presented below. 2.3.1 One coordination mechanism: Organizational structure - link to the Ministry of Health, avoiding verticality that might be imposed by donors. (2) Leadership - identify people and agencies; there may be a step above the Ministry of Health that will lead this process. (3) Funding mechanism - budget and plan for coordination and planning. (4) Evaluation and review - monitor coordination processes and report against progress. (1) One plan: Leadership - gain commitment at highest political level, on the basis of the Regional Strategy. Integration and involvement of all stakeholders - distribution of the Regional Strategy. 'Situation-of-children' review. Policy analysis - for current activity and lessons learnt. Formulation of plan - time-bound, targeted, measurable. Resource implications. Possible dissemination and implementation. One monitoring and evaluation mechanism: Clarify starting point. Sources offundinglresources for monitoring and evaluation. Key stakeholders. 'Buy-in' of political stakeholders to evaluation. Core indicator development and refinement. Integration with existing systems. Development of human resources.
2.3.2 (I)
(2) (3) (4) (5) (6) (7) 2.3.3 (1) (2) (3) (4) (5) (6) (7)
9 (8) (9) 2.3.4 Feedback, quality assurance. Dissemination of findings. Mobilize advocacy and communication
Advocacy is very important. This may need to precede the communication component. There is a need to 'sell' child survival and the strategy. This will include creation of persuasive arguments for change, giving people a reason to change. (1)
(2) (3)
(4)
What to communicate? - identification of key messages, start from the Regional Strategy, clear, simple and prioritized - perhaps better to develop the key messages at the community level. Who will communicate? - professional societies, media, community, parents, NGOs, front-line health workers. How to communicate? - identifY stakeholders, channels and methods, including social organizations - inform+engage+convince - partners, especially education, including children. Who are the targets? - stakeholders again (do not forget local-level health workers), local government and communities, and look for those who have been previously uninvolved. Mobilize resources to accelerate and sustain child survival
2.3.5 (1)
(2) (3)
(4)
(5)
Have a clear advocacy plan - commitment to finance and planning ministries; awareness to policy-makers, child survival team; and a two-track strategy - one for external and one for internal sources (this may have implications for the structure of the Regional Strategy). Involve the community - community resources and social capital - and review and involve existing actors, NGOs. Coordination - of 'donors', possibly a regional alliance - emphasize that the package is a whole and should not be fragmented - also in-country partnerships, including professional societies. Transparency and costing - avoid duplication and fragmentation, present clear implications and costs to donors, engage support from other external agencies (e.g. Bill and Melinda Gates Foundation), appeal to rich countries to increase their stated development commitments, publicise what governments spend on child health (the East Asia and Pacific Region has the lowest average percentage spending on health in the world). Support - involve the Ministry of Health, account for human resource assumptions and other resource assumptions.
Present the evidence to donors, perhaps by way of pilots - third-party evaluation. However, this is not a new progranune. It is more about presenting the rationale for scaling up with well tested and established interventions. Also allow piecemeal contributions that contribute to parts of the package without compromising its integrity.
10 3. CONCLUSIONS
3.1
Objective 1: Review and discuss past experiences in child survival and lessons learnt The meeting concluded that: • child survival interventions have good evidence of efficacy; and • the global community has failed children by not allocating sufficient resources to applying those interventions on a sufficient scale.
3.2
Objective 2: Review and make recommendations on the draft Regional Child Survival Strategy
The meeting concluded that the strategy could request countries to set their own targets within the objectives, linking to MDG4. The goal and objectives were generally agreed as reworded on day 2. The categorization of countries was also agreed. It could also be applied within countries, such as China. The meeting recommended that the Regional Strategy should be brief, clear, visionary and oriented towards advocacy. It should: • • • • • include an essential package of interventions; include complementary interventions and interventions that address underlying causes; be measured, with a commitment to equity; aim at universal coverage with the essential package; and provide direction for organizing and mobilizing implementation in countries.
Equity should be the chief priority in planning, implementation and monitoring. There was general agreement on inclusive coverage of the poorest, with particular actions to achieve this. The meeting concluded that there should be no conflict between IMCI and the Regional Strategy and the need for integration at every level should be highlighted. The essential package should include seven items, roughly corresponding to: • • • • • • • skilled attendance during pregnancy, delivery and immediate post partum; care of the newborn infant; promotion of breast-feeding and complementary feeding; micronutrient supplementation; immunization of children and mothers; integrated case management of diarrhoea, pneumonia and malaria; and insecticide-treated bednets.
Good cooperation between maternal, reproductive health and family planning are essential. If birth spacing and PMTCT are not included in the essential package, they must be strongly highlighted in the section previously called 'The Enabling Environment'. The issues of nutrition and referral care were referred to the secretariat for consideration. The title of this section was also left for the secretariat to decide. The content should focus on: • • birth-spacing; water and sanitation;
11 • • PMTCT; and women's education, empowennent and gender equality.
The meeting concluded that structuring the section on policy environment, planning and resources, as part of the way forward, would be most helpful. It could match the framework of the three 'Ones' and the two 'Ms'. The community should also feature heavily in the document, particularly in the discussion of opportunities for delivery of the essential package. Equity measures should be included in monitoring, and the final list of indicators presented on day 3 was referred to the secretariat. 3.3 Objective 3: Discuss and plan approaches to scaling up child survival actions
The meeting agreed, through a participatory planning exercise, on an approach to scaling up based on: • • • • • one coordination mechanism; one plan; one monitoring and evaluation system; mobilizing for advocacy and communication; and mobilizing resources to accelerate and sustain child survival.
The meeting concluded with thanks to all participants for their contributions and work towards improving child survival in the Region. The secretariat was tasked with finalization of the strategy for presentation at the 56 th Session of the WHO Regional Committee for the Western Pacific in September 2005.
ANNEX 1
LIST OF TEMPORARY ADVISERS, RESOURCE PERSON, REPRESENTATNES/OBSERVERS, AND SECRETARlAT 1. TEMPORARY ADVISERS Dato' Dr Narimah A WIN Director, Farrrily Health and Development Div. Department of Public Health Ministry of Health Level 8, Block E 10, Parcel E Federal Government Administration Centre 62590 Putrajaya Kuala Lumpur, Malaysia Tel. no.: 603-88834001 Fax no.: 603-88886175 Email: narimah@moh.gov.my Dr Honorata CATIBOG Director III - National Center for Disease Prevention and Control Family Health Office Department of Health Bldg. 13 - NCDPC - FHO San Lazaro Compound, Sta. Cruz Manila, Philippines Tel. no.: (632) 732-9956 Fax no.: (632) 711-6130 E-mail: art_sunshine@yahoo.com Dr DINH Thi Phuong Hoa Deputy Director Reproductive Health Department Ministry of Health Ha Noi, Viet Nam Tel. no.: (844) 832 5815 Fax no.: (844) 736 6442 Email: hoadp@fpt.vn
Dr Somchit AKKHAVONG Deputy Director Department of Hygiene and Prevention Ministry of Health Vientiane, Lao People's Democratic Republic Tel. no.: (856) 561 8040 Fax no.: (856) 252911 Email..svilayrack@yahoo.com
Professor Lulu BRAVO Head, Paediatric Infectious Diseases College of Medicine University of the Philippines Manila, Philippines Tel. no.: (632) 526-9167; 404-2397 Fax no.: (632) 526-0150 Email: 1cbravopids@uplink.com.ph; lulubravo@yahoo.com
Dr DAl Yaohua Head, WHO Collaborating Center for Child Health Capital Institute of Paediatrics No.2 Ya Bao Road Beijing 100020 People's Republic of China Tel. no.: (8610) 85636169 Fax no.: (8610) 85622025 Email: yh.dai@263.net
Annex 1 Dr Trevor DUKE Senior Lecturer Department of Paediatrics Royal Children's Hospital and University of Melbourne Parkville, Victoria 3052 Australia Tel. no.: (613) 9345 5968 Fax no.: (613) 9345 6000 Email: trevor.duke@rch.org.au Dr HONG Rathmony Deputy Director Communicable Disease Control Department Ministry of Health #151-153 Kampuchea Krom Avenue Phnom Penh, Cambodia Tel. no.: (855) 16965499 Fax no.: (855) 23 880532 Email: rathmony_hong@online.com.kh Dr Tadatoshi KURATSUJI Director -General, Research Institute National Center for Child Health and Development 2-10-1 Okura Setagaya-ku Tokvo 157-8535, Japan Tel. no.: 81334160181 ext. 4051 Fax no.: 81 3 5494 7084 Email: tkuratsuji@nch.go.jp Dr Christopher MORGAN International Child Health Speciahst Burnet Institute G.P.O. Box 2284 Melbourne, Victoria 3001 Austraha Tel. no.: (613) 92822110 (614) 14761959 (mobile) Fax no.: (613) 92822100 Email: cmorgan@burnet.edu.au Dr GOCHOO Soyolgerel Officer for Child and Adolescent Health Ministry of Health P.O. Box 49/627 U1aanbaatar 210349 Mongolia Tel. no.: (976) 91910655 (mobile) Fax no.: (976) 11320916 Email: gsoyoloo@yahoo.co.uk Professor KOUM Kanal Director National Maternal and Child Health Center Ministry of Health NMCHC, Street France Chak, Daun Penh Phnom Penh, Cambodia Tel. no.: (855) 12963785 Email: nmchc@online.com.kh koumkanal@comnet.com.kh Dr David MOKELA Chief Paediatrician Port Moresby General Hospital Free Mail Bag Boroko, NCD Papua New Guinea Tel. no.: (675) 324 8200/324 8282 Fax no.: (675) 325 0342 Email: healthsec@health.gov.pg NGUYEN Cong Khan Director National Institute of Nutrition 48b Trang Bat Ho Street Ha Noi, Viet Nam Tel. no.: (84-4) 971-6058 Fax no.: (844) 971 7885 Email: nckhan@hn.vnn.vn
Annex I
Dr Elizabeth RODGERS Associate Professor Paediatrics Fiji School of Medicine Private Mail Bag Suva, Fiji Tel. no.: (679) 3311700 ext. 1515 or 3233515 (679) 9268659 (mobile) Fax no.: clo (697) 3308122 Email: e.rodgers@fsm.ac.fij Dr Nicola TURNER Clinical Director, Senior Lecturer Department of General Practice and Primary Health Care School of Population Health University of Auckland P.O. Box 17360, Greenlane Auckland, New Zealand Tel. no.: (649) 5798677; 3737599 ext. 82565 Fax no. (649) 3737030 Email: n.tumer@auckland.ac.nz
Dr TUNG Rathavy Deputy National Programme Manager National Reproductive Health Program National Maternal and Child Health Center NMCHC, Street France Chak, Daun Penh Phnom Penh, Cambodia Tel. no.: (855) 12222773 E-mail: rathavy@online.com.kh
2. Dr Cesar VICTORA Universidade Federal de Pelotas c.P. 464-96001-970 Pelotas RS, Brazil Tel. no.: (55) 53271 2442 Fax no.: (55) 53 271 2645 Email: cvictora@terra.com.br 3.
RESOURCE PERSON
REPRESENT ATIVES/OBSERVERS
Dr Koji SASAKI Health Attache Embassy of Japan in the Philippines 2627 Roxas Boulevard Pasay City l300 Philippines Tel. no.: (632) 551-5710 Fax no.: (632) 551-5783 Email: keizai4@japanembassy.ph
Dr Florence V. TIENZO Health Specialist The World Bank 23,d Floor, Taipan Place F. Ortigas Avenue, Ortigas Center Pasig City, Philippines Tel. no.: (632) 917-3095 Fax no.: (632) 637-5870 Email: ftienzo@worldbankorg
Annex 1 4. WHO WESTERN PACIFIC REGION Dr Linda MILAN Director, Division of Building Healthy Communities and Populations WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9986 Fax no.: (632) 521 1036 Email: rnilanl@wpro.who.int Dr Marianna TRIAS (Responsible Officer) Medical Officer, Child and Adolescent Health and Development Division of Building Healthy Communities and Populations WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9868 Fax no.: (632) 521 1036 Email: triasm@wpro.who.int Dr Hans TROEDSSON The WHO Representative in Viet Nam 63 Tran Hung Dao Street Hoan Kiem District P.O. Box 52 Ha Noi, Socialist Republic of Viet Nam Tel. no: (844) 943- 3734 to 36 Fax no.: (844) 943-3740 Email: troedssonh@vtn.wpro.who.int SECRETARIAT
Dr James TULLOCH The WHO Representative in Cambodia No. 177-179 comer Pasteur (51) and 254 P.O. Box 1217 Sangkat Chaktomouk Khan Daun Penh Phnom Penh, Cambodia Tel. no.: (855) 23-216610 Fax no.: (855) 23-216211 Email: tullochj@cam.wpro.who.int
Mr Wayne ANTKOWIAK Technical Officer, Expanded Programme on Immunization Division, Combating Communicable Diseases WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9751 Fax no.: (632) 521 1036 Email: antkowiakw@wpro.who.int Dr Luca Tommaso CAVALLI-SFORZA Regional Adviser in Nutrition and Food Safety Division of Building Healthy Communities and Populations WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9864 Fax no.: (632) 521 1036 Email: cavalli_sforza@wpro.who.int
Mr Henrik AXELSON Associate Professional Officer Health Care Financing WHO Representative Office in Viet Nam 63 Tran Hung Dao Street Hoan Kiem District P.O. Box 52 Ha Noi, Socialist Republic of Viet Nam Tel. no: (844) 943- 3734 to 36 Fax no.: (844) 943-3740 Email: axelsonh@vtn.wpro.who.int Dr Eva-Maria CHRISTOPHEL Medical Officer, Malaria, Vectorborne and other Parasitic Diseases Division Combating COlmnunicable Diseases WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9722 Fax no.: (632) 521 1036 Email: christophele@wpro.who.int
Annex 1
Dr Graham HARRISON Regional Adviser Health Systems Development Division of Health Sector Development WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9806 Fax no.: (632) 521 1036 Email: harrisong@wpro.who.int Dr PANG Ruyan Regional Adviser in Reproductive Health Division of Building Healthy Communities and Populations WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9876 Fax no.: (632) 521 1036 Email: pangr@wpro.who.int Dr Reijo SALMELA Scientist, Situational Analysis for Policy Division of Health Sector Development WHO Regional Office for the Western Pacific Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9835 Fax no.: (632) 521 1036 Email: salmelar@wpro.who.int Dr Severin von XYLANDER Medical Officer Child and Adolescent Health and Development WHO Representative Office in Cambodia No. 177-179 corner Pasteur (51) and 254 P.O. Box 1217 Sangkat Chaktomouk Khan Daun Penh Phnom Penh, Cambodia Tel. no.: (855) Fax no.: (855) 23-216211 Email: xylanders@cam.wpro.who.int
Dr Carolyn MACLENNAN Short-term Professional, Child and Adolescent Health and Development Division of Building Healthy Communities and Populations WHO Regional Office for the Western Pacific United Nations Avenue P.O. Box 2932 1000 Manila, Philippines Tel. no.: (632) 528 9866 Fax no.: (632) 521 1036 Email: maciennanc@wpro.who.int Dr Andre Ernst REIFFER Technical Officer WHO Representative Office in Papua New Guinea P.O. Box 5896 Boroko, NeD Papua New Guinea Tel. no.: (675) 325-7827 Fax no.: (675) 325-0568 Email: reiffera@png.wpro.who.int
Dr Howard SOBEL Medical Officer, Expanded Programme on Immunization WHO Representative Office in the Philippines P.O. Box 2932 Manila, Philippines Tel. no.: (632) 528-9768 Fax no.: (632) 731-3914 Email: sobelh@phl.wpro.who.int
Annex 1 WHO HEADOUARTERS Dr Elizabeth MASON Director, Department of Child and Adolescent Health and Development World Health Organization Avenue Appia 20 CH-121I Geneva 27, Switzerland Tel. no.: (41 22) 791 3281 Fax no.: (4122) 7913111 Email: masone@who.int Dr Robert SCHERPBIER Medical Officer, Child and Adolescent Health and Development World Health Organization Avenue Appia 20 CH-1211 Geneva 27, Switzerland Tel. no.: (4122) 7912693 Fax no.: (4122) 7914853 Email: ScherpbierR@who.int
WHO REGIONAL OFFICE FOR SOUTH-EAST ASIA Dr Sudhansh MALHOTRA Regional Advisor Child Health and Development WHO Regional Office for South-East Asia World Health House Indraprastha Estate Mahatma Gandhi Road New Delhi - 110002, India Tel. no.: (9111) 23370804 Fax no.: (9111) 23378510 Email: malhotras@whosea.org
UNITED NATIONS CHILDREN'S FUND Ms Anupama Rao SINGH Regional Director UNICEF East Asia and Pacific Regional Office 19 Phra Atit Road P.O. Box 2-154 Bangkok 10200 Thailand Tel. no.: (662) 280 5831 Fax no.: (662) 280-3563 to 64 Email: asingh@unicef.org Ms Karen CODLING Regional Nutrition Officer UNICEF East Asia and Pacific Regional Office 19 Phra Atit Road Bangkok 10200 Thailand Tel. no.: (662) 356 9420 Fax no.: (662) 280 3563 to 64 Email: kcodling@unicef.org Dr Stephen ATWOOD Regional Advisor, Health and Nutrition UNICEF East Asia and Pacific Regional Office 19 Phra Atit Road Bangkok 10200 Thailand Tel. no.: (662) 356 9417 Fax no.: (662) 280 3563 Email: satwood@unicef.org Mr Colin DAVIS SPO and Officer in Charge UNICEF Philippines 31 st Floor Yuchengco Tower RCBC Plaza, 6819 Ayala Avenue Makati City, Philippines Tel. no.: (632) 901 0126 Fax no.: (632) 901-0195/96 Email: cdavis@unicef.org
Annex 1
Dr lama GULAID Chief, Health and Nutrition Section UNICEF Viet Nam No. 72 Ly Thuong Kiet Street Ha Noi, Viet Nam Tel. no.: 8449425706 Fax no.: 8449425705 Email: jgulaid@unicef.org
Ms Susan MACKAY Regional Programme Communication Officer Expanded Programme on Immunization UNICEF East Asia and Pacific Regional Office 19 Phra Atit Road Bangkok 10200 Thailand Tel. no.: (662) 356-9206 Fax no.: (662)2805831 Email: smackay@unicef.org Dr Koenraad V ANORMELINGEN Chief, Health and Nutrition UNICEF China Country Office Beijing, People's Republic of China Tel. no.: (86-10) 6532 3131 ext. 1601 (86) 139 10196606 (mobile) Fax no.: (86-10) 6532 3107 Email: kvanormeIingen@unicef.org
Dr Romanus MKERENGA Chief, Health and Nutrition UNICEF Philippines 31 st Floor Yuchengco Tower RCBC Plaza, 6819 Ayala Avenue Makati City. Philippines Tel. no.: (632) 901 0150 Fax no.: (632) 901-0195/96 Email: rmkerenga@unicef.org
TECHNICAL CONSULTATION ON THE CHILD SURVIVAL STRATEGY 10-12 May 2005, Manila, Philippines PROVISIONAL TIMETABLE Time 08:00 Tuesday, 10 May Registration l. Opening (including group photo) Wednesday, 11 May Evidence for child survival interventions Discussion 7.
9 May 2005 WPR!ICP!CHD!3.1!001
Thursday, 12 May ll. Plenary discussion on group work
to
10:00 10:15 2. Adoption of objectives and agenda Objective 1: Review and discuss past experiences Eor child survial and leassons learnt 3. Past experiences for child survival and lessons learnt 4. Country experiences: Gains in child health lessons learnt • Malaysia Viet Nam Discussion
C 0 F FEE B REA K 8. country grouping Discussion
to
Objective 3: Discuss and plan approaches to scaling up child survival actions 12. Approaches to improving child survival actions 13 . Group work: the way forward
12 :00
•
13 :00
to
Objective 2: Review and make recommendations on the draEt Regional Child Survival Strategy 5. Highlights of the WHO/UNICEF Regional child survival strategy Discussion
L U N C H B REA K Implementation in three target areas 9.
14. Plenary discussion on group work Conclusions
14:30 14:45 to 16. Closing 15:30 --
6. Essential package for child survival
C 0 F FEE B REA K 10. Group work: technical review of the Regional strategy
15. Summary
I N
ANNEX 3
WPRO May 2005
Outline of presentation
Past experiences for child survival and lessons leamed
- Lancet Child Survival series and recent developments • New CHERG estimates • Lancet Neonatal Survival Series • Lancet Health Systems Series • Co-coverage Of d'lild survival interventions
Cesar Victora and Liz Mason
- World Health Report 2005
Deaths by selected groups of causes, 2003 Under.flve
AiDS Tuberculosis M.I.rI~
Maternal Tropical, nOlHT'lilllaria
.f-----+---+--+--+---+--~ 10 Annual death5 (mllllon5)
12
2
Lancet Child Survival Series _111~
o o 3
Idil'" ~,,",n:-nI
g
2
o
o 3 10.7 million children die
every year Main causes of death neonatal conditions
:!!:!!1Iow1"'~lt;;;i."~_:';;;":;;jl--------
~-.~~,,,~,~~,~,-------------
- diarrhoea - pneumonia malaria
='::'':=':r-;;:~-~;:''j---------
Malnutrition is an underlying cause of over 50% ci deaths 42 countries account for 90% of all deaths
1 c\ot:5,OOOdeathti
Annex 3 2 Ne!.lJl<1ttal )lJlVlvail
4 million neonatal deaths: When?Wher\!?Why?
--,--,-...,--.
o -,-----~- ....... :---- _ _ _ II.
WHO estimates atthe causes of death In children
o 5
4 million annual deaths Growing proportion of all underfive deaths Little progress in last 10·15
years Low blrthweight is an irTl'Ortant contributing cause Highest risk on first day of life
I~' " A'4'I'Y~'~ lj"
""-"
l· ,. i-··PM~~]k
,:':'""'9<'f1lI'I~"
Updated global estimates of underfive deaths, 2000-03
2 How many child death. ean we p",,,enl this YNr'I I_~."-
_.
o o _,~
Reducing child mortality: can public health deliver?
o __ "'.
""''\,.... W
SIr_
~)I!~li
r""'... (_ ... ..."",.. ~
_"~
...",,,, ... ....... ~
"" ....
~,._
3
__foo'D"""'.., _ _ ""'.... ......<.___"'_a ..... '~"'''''''·
_ I ..... "':>O._"",~_~~,
63"10 01 all child deaths may be prevented by reaching
universal coverage with 23 feasible, low cost interventions - ORT - Breastfeeding promotion Insecticide treated malefials
- Anllbiotics - Etc.
Life-saving interventi~ns are not reaching most children Weak health systems - costs of training - stafftumoVef - lack of regular supervisIOn - low utilization rates! klw accessibility Inability to reach communities - poor caTl~..seeking practice'S - low (;Overage of preventive Interventions Need to concentrate on delivery channels
2
Peru: facility and community IMel were not implemented in the same areas Departmental coverage of IMel-trained clinical and cornnunity workers (2003)
o 3
Reducing: child mortality.: can public heatth deliver?
».-_.s.......... _ _ "..... """-,'t........ _.(;<n<tr>~,.rr¥:O_;.o""'·
,~_~_
.......
,_~
............ """''''',
Currenl delivery strategies for child survival interventions
are inadequate. and coverage is low One-size-fits-all delivery strategies are not appropriate Altemative approaches to health services must be considered to reach high and equitable coverage
Local capacity is needed to Identify epidemiOlogical profile - Select interventiOns - Choose delivery strategies - Monitor implementation
20
30
<10
Tl'lIIIlned clinical health wOtkers (%0)
Annex 3 Np.onatal StJlvivai 2
2
Evidence.based, ~s:t·(!ffectNP. intH'Yenlions: hOW' many
newbombabiuunweSMIe? .... ,____...... ~ " " " " '
........
o o 5
; . . _ $ . > M __ ,'_'
'
1
0
<
.
16 interventions with proven efficacy Combined into packages for scaling up
3 service delivery modes - Outreach Family-community
- Fadllty-based dinical care
UnivetSal (99%) coverage of these Interventions could prevent 41-72% of neonatal deaths worldwide - Mosl of thiS benefit Is derived from f9f'llily-commurVty care Greater effect where neonatal morality is very high
_
Nt':Onatal Survival)
2
Systenntlc Killing up of neonatal care k1 (oontries -~..-..
•
..---....d._~.:_
...,-....
,--,-----.-~."",-,
..............
o o ~
5
Lancet Health Systems Series Equity Financing Human Resources Scaling up Health systems
'= "
o 4
Step 1: Assess the situation and create a policyenYironment conducive to neonatal health Step 2: Achieve optimum neonatal care within the constraints of the situation - Start with outreach (y lamuy.commonity cate If tI'1e health svstem IS
-
not strong Identify and address missed opportunities within the fQfmal healthcare system Coordinate across progillmmes relevant to neonatal health
Step 3: Systematically scale-up neonatal care - Strengthen supply and demand sides
research priorities
Step 4: Monitor coverage and measure effect and cost
I (;iiiLi .",,1"1'1 h I _ _ I. not enough Applylnlon equtty leM to child heetth and nwrtaltty: rr-e of the
!
t_bi)J~ .. 1'VfYI\i 1\
! ~e
2 of the
o 3
AppI',tng lUll equity 1 _ to child h.atth and mortality: -.me' I. not enough
r. __" _... """",,,_ _ _
IIJ'_U""_...... '_,--......--. ........ "".,_ ..........
:1 Mortality ratios between rich and poor countries
s ....
_?
,3' / I"
Withincountry inequities are often large
are increasing
~ f"j .~a~
. """-
Sovrce: PovertyNel websile
Armex 3 I ChiJd ~Ur'\'1VAl J\ I Apptying an equity .... to child health and mortality: nwre of the INIme
2
! Ould ~un:tWi it !
2
o o 3
Is mt enoup
AppIylna: an equity hm5 to child health and mortality: more of the &II1II8 I. not -nouah
o o
More likely to be exposed to disease agents Less likely to receive preventive intetVentions More likely to acquire disease Lower resistance to disease
Lower access to health facilities Less likely to be managed appropriately in health facilities Less likely to get life-saving drugs
Govemments often spend more with the rich than with the poor
i
t~
U...- r - = RIoI>utOullrtll1 aMriaa CE""t Eu ...... BAlM
•
Preker A, World Bart;
!child wn:{"m \!
2
2 Neon.t.1l SurvlV.ll4
Knowledge Into action lor chid survival
o o 3
Neonatal survival: a call for action
..'__·"',.,..,.,.,.-.......... -.......""'-.'"',""""__ M'......,'.,..,..'.,.""'""",..,·,... __ *.....,...... OM'''' '."" ....... d·........
o o 5
The Child Survival Revolution of the 1980's saved millions of child lives Child deaths outnumber HIV.
Available, feasible interventions could prevent 6 million (63%)
child deaths if they reached all mothers and children We now need a Second Child Survival revolution to complete this unfinished agenda Global leadership is badly needed
malaria and tuberculosis deaths
combined. Child survival has fallen off the international agenda
Reducing neonatal deaths is essential for reaching MDG-4 Success is possible even in low-income countries 41-72% of neonatal deaths may be prevented Interventions ~rough
The costs of scaling up neonatal interventions
are affordable 70% of this spending will also benefit mothers and older children Neonatal care should be
i!l'N-COSI
Funding for child survival is decreasing in relative, and for
incorporated into Safe Motherhood and IMGI
some donors in absolute terms
strategies
Today's grandest challenge How to deliver the effective, low-cost interventions that we already have, to those who need them most? Primary concern: equity through universal coverage
Update on equity
Co-coverage of child survival interventions
Cesar Viciora, Bridget Fenn,
Need to match interventions to epi profile and to delivery channels
Jennifer Bryce, Betty Kirkwood
Annex 3
Co-coverage: methods Selected 9 preventive child survival Interventions measured through DHS - water - al'll8llatal care (>=" viSits) - ~dellvery - TT (2 doae& In pregnancy)
% <5 children according to the number of child survival interventions received, by country o &-1111
Used DHS data for 9 countries Bangladesh
2
4 tI IS
5 21 ,. ,. 11 14
B+
_ Benin
- B"" -
- cambodia Eribea Haiti Malawi Nepal Nicaragua
t"
II
-BCG OPT (3 ooses)
" "
-
- measles vaccine vitamin A bedMtS
-
Calculated assellnde)C kl classify wealth
Calculated how many of these ~
interventions were recetlled by aged 1-4 years
% <5 children according to the number of interventions received, by wealth quintile
% <5 children receiving 6+ child survival interventions, by wealth quintile and country 100%
..." 20-,,0%
.."
." ,,/ P ......
L d 2nd
;Y-
/ 3n1
..h
Least poor
% <5 children receiving 6+ child survival interventions, by wealth quintile and country Bottom inequity
Co-coverage: summary Some children receive many interventions while others receive few or none
.u.. .,...."
~
~%t=~~§§~~~~~/~:~~-~ ~ .. ~ , Poorest 2nd 3rc! 4th Least poor
&D%t---
L
~
Co-coverage is clearly related to wealth Children with many interventions have lower mortality Due to the interventions per se Due to lower baseline risk (food. parental education, care, housing, etc)
Top inequity
Annex 3
Co-coverage: policy implications More lives will be saved by universal coverage with few interventions than by adding new ones to an inequitable situation ·Packaging- may Seem to make economic sense but mediocre coverage with an inequitable package is the worst-ease scenario
Universal coverage is the ultimate goal • Targeting may be useful in Nbottom inequity" situations
Evidence for newborn and child survival interventions and impact Technical consultation on the child survival strategy Manila, 11 May 2005 Cesar Viclora
lancer. June 2003
sm -MCE
EVIDENCE FOR CHILD SURVIVAL INTERVENTIONS
Global Research & Development investments per DAL Y • Efficacy
Identifying effective child survival interventions
• Global average (all diseases): US$73 • HIV/AIDS, malaria and TB: US$8.4 • Acute respiratory infections: US$0.51 • Diarrhea: US$0.32
• Does the Intervention have an impad when optimally Inwlerrented?
• Effectiveness
• Does the intervention nave an impact under routine ImpJementatkln conditions?
Identifying effective child survival interventions • Assessed the evidence far the effectiveness of interventions to reduce child mortality from each
88~8B
of the major direct and underlying causes of death in children younger than 5 years. Considered only interventions feasible for high levels of implementation in low·income countries. Assigned interventions
to one of three levels:
- Level 1. Suffic;lsnt evidence - Level 2. limited evidence - Level 3. Inadequate evidence
Identifying effective child survival interventions 23 IntllfVenUon.
000000110
nnU88~ oooooo~~ 8g88ii88~B
000000110. OOD~000I&..
gg~~g81ii~8
15 preventtv. a curatlw
Annex 3 Prevention interventions addressing major causes of under five death Deaths prevented Prevention Intervention
Treatment interventions addressing major causes of under five death Treatment Intervention Numb.r tt.o ....n ..
Number as proportion of .n child deaths ltIou..... 1301 691 587 459 403 411 13% 7% 6% 5% 4't,
Deaths prevented as proportion of all child deaths
Bre"~OOlIJI1Q lnS'e'cijqld$~tre.~:r:iratIJHBls
OrSf"'h~d!irtr'''i't!\ii¥j I\IIH~Oif<iS":fiit~~P$I. Arirlbit)tI~:ror, 'PfI$lJmbnla ,yiUmaJ8tiar~
1471
15% 8% 6% 5% 4% 5% 3%
583 577 467 394 467
Complajill!1iofy.feOOln& Zinc H influenzae vaccine
ZIiiolOtd""",,".
Cleen delivO(y Water, sanitation, hygIene
NBWbOrr:il.i'8suscltBtlO(l Aiitl~tk:a for
dYHntarj
310
Global annual R&D investments per DALY
The evidence gap: Global average (all diseases): US$73 • HIV/AIDS, malaria and TB: US$8.4 Acute respiratory infections: US$O.51 Diarrhea: US$O.32
Neonatal interventions
o.
,GFHR ,"""
Identifying effective newborn survival interventions Studies were assessed studies for size, design, quality, and setting. Five level of evidence categories were used: - I. Evidence of no benefit. - II. No evidence of benefit. - III. Uncertain evidence of benefit. IV. Evidence of efficacy. V. Evidence of efficac and effectiveness
EVIDENCE Lsn ..~ Ma,.h zoos FOR NEWBORN SURVIVAL INTERVENTIONS
Annex 3 Timing Pra-con~ptlCII'I
Natura of [ntaNention
'.Ilo ..w ...._ _ ... T _ _ • • I111 .....
AnWNltal
""'' '110 ... _ ....... __ , . _ .......0001 ........... ~u.aU.,II_) .......11 _ _ _ """ _ •••,"'..., .. • ..,.Ior ••
_U..
L..,eI of evlcJtlnca W
TIming Pr~on~ptian
NBtuJlI of Intervention
"'I...
IoI ... ,.~Io
..... hI'''. on.
I.evelot Ivldence
W
"
S)'pIoIIIo ....- . ."" .......
IV
InbapartLlm
............,,..-,.,....hInt,...._.r ___ c.r.ID ......... (D .......nn .....""
lleI..u.n .ntI I..........U .r ",...rc....1k _
IM,.,............... ,U•••bl_.,a.._1I) t.o_ "'"""..... ,_ ...... ~. ."'pb) .rlf~........r
• • W
w w
l
Intn,..rturn
-:--:--JI~-~~-~''''~' 'j{;~::,,-;~~b!~d:lflI~C~r'· D&lMI~n .1MI1':~~~j;·~'~~:~'li:'~~~~:i-'d~~ih~_= AlII ........
•• _10",,,,,10 ,lUI .1Iom ..............._n 'AI""!,!I
r.r...-.. ,......-,........... v, ._ .... _
==tj"E3 IV IV IV
"mil..........
c .........".f'I"I._ Postnatal
JIj--. ........ . . . 11....... , . _. . . . . . ._ _ l1li • .."...........
• • "
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rv
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Po.tnatal
N-*'"'n .... _ .......
~
a...'f........ .............._ ....... ~.."..I_ ..
• v
KoI .................. (LaW _III. III
_l1li 'ullll_1
c•••MIt......"'" _
.... _
............
"" ...... ..uou nn(UlW 1n'.III. II1 ....JtIo full",,",) eo.. IIIUllltt-bu.. _ .... _ _ ........1
"
31 cost-effective interventions
MULTI-COUNTRY IMCI EVALUATION
EVIDENCE FOR CHILD SURVIVAL INTERVENTIONS PACKAGED AS IMel
MCE Independent evaluation Intemational group of technical advisors National principal investigators 12 country visits, 5 in-depth studies Financed by Gates Foundation
IMel and child survival
,MCE
rami
Annex 3
IMel includes effective interventions Anti biotics for pneumonia Vaccines Oral rehydration therapy Antimalarials Insecticide- treated materials Breastfeeding and nutrition counselling Anaemia treatment Vitamin A supplemenlation etc.
IMCI improves health worker performance • Non-IMCI .IMCI
·MCE
IMCI training of health workers also requires Health systems strengthening Drugs SupeNision Referral Utllizationl access District management $$$$$$$
mm MCE
Low utilization of health facilities may limit the impact of IMCI on the short-term %
$ick chldren who went taken first to a government fadllty
Householdcommunity level interventions - Careseeking - Home management - Nutrition
Bangw.desh
-etc
" Sourc.: Arttll," 5, Piryto G. Scnell..,btlrg J "II
.B:~. .~.... " .. ~1ll'I!'7.ii':':i\lili"l\1i1r.d':''1i''.iMCE .. _.~ _~.~q;m"' ..•"'..____ "'.~_"""' ..
·=·~··"::~";·~'~d·"';;''l.'fu.ji!m~;;;'n''d
MCE
mm
----
---.-..,......._'" .... ..... ...-.,.........'-'-----~ "
Effectivtnen ind cost of ~ty.bit5«l.lnt:eIJ'lted Minagrmen1 af Chddhooo Ilness (lMCllm ianzania
_--
Tanzania impact: IMCI x non-IMC after 2 years
-
""'"-~
.. Underfive mortality - Reduction of 13% - Prevention of 4 deaths per 1,000 childrenl year
MCE in Tanzania - 2 IMCI x 2 matched comparison districts - Effectiveness study in site with -0 istriet health strengthening ·H igh quality training of heallh workers
Stunting - Significant reduction in stunting
- High utilization by the population
Equity - Slight improvement in equity in IMel districts
MCE
mID
.MCE
mm
Annex 3
In Tanzania, IMCI did not cost more than routine child care
Cost per child managed correctly in Tanzania Cost per child correctly managed, Tanzania (1999 US$)
!
;; '" ,-----..c;------, 116
::. 11<1
B •• se HospllalCO$1: e><ClUlled
~ $4
I iu
fi
~ 512 110 $8
$25
$6
M el:
/
__-- _..
Integratfd MalwgeIlllInt of O\lldhood lijnog. (IMCI) in
bngladt$lr early ~9' a clucltr.nndomiMd _ _ ......: _ t* -..... ' fmm __ _ _ .... _ _ rtudy _
_". . . . _,-...0-,.-.._._, ___....__ _ -~ ... ..
-_ __
Health facility utilization increased in IMCI areas in Bangladesh !-IMCllntervanUon _IMel Camp.rison
I
• Bangladesh MCE - Randomized trial of lOx 10 catchment areas - Efficacy study ·H ealth worker training 'C ommunity IMCI ·H ealth systems inputs
~
~ i~ 1;.
~ ,~
.JV ,
"-"
.LJL!..
- Preliminary results (end in 2007)
~1141',11111·'1111·.111 _ 1 _ - - ' 1 _ _ _ ~ _ _ _ _ .}lH
..---. .
What have we learned from the MCE? IMCI improves quality of care in health facilities Health systems matter! The key issue is how to achieve and maintain high population coverage - Requires community delivery channels in many countries
Conclusions low-cost interventions exisl.. ..to address newborn mortality: 16 interventions .• to address under five mortality: 31 interventions, including the 16 above .. and can be highly cost-effective
It is essential to address inequities
Annex 3 IMCI and child survival: Countries with functioning health systems IMCI and child survival: Countries with weak health systems
Annex 3 A simple set of affordable, effective interventions are available Integrated Management of Childhood nIness (IMel): one such viable strategyaddresses Integration at three levels of care (patient, point of delivery, system). Community interventions include newborn care and care of the older child EPI Plus - extends EPI beyond traditional boundaries and includes Vit. A, bednet distribution
ll .. '\hljl-blll~~;,t;'..MR"-..y~
ami
~f>ikf
I>OIInt
The two meanings of "continuum of care" A continuum that spans life's beginnings: - from before conception to childhood through pregnancy, childbirth and infancy.
Reconciling MNCH with health systems development Strategies that cross boundaries between maternal, newborn and child programmes. Synergies between MNCH programmes and environmental protection, gender equality and poverty reduction. Linlai between MNCH programmes and COTe health systems development processes with investment plans that: - overcome the systemic constraints on scaling up; - embed MNCH in an overriding project of ensuring universal coverage. World Hcahh Orgwrna,ia" Aprll 05
A continuum that goes from: - the home (empowering families); - through the health centre (bringing care closer to home); - and, when needed, to the hospital (facilitating referral).
World HI!Difll Orgrmi!alim, April OJ
Universal coverage Universal access requires: . sufficient supply of services; - no financial barriers to uptake of services.
Organizing the financing of the health sector for universal coverage Shift from user fees to pre-payment and pooling. Consider an sources of funding: • Both domestic and international funding; • Need for increased public spending
Protection against financial consequences: - more than 100 million individuals in the world each year are pushed into poverty as a result of spending money on health care.
Start to build national health insurance schemes (tax-based, social health insurance, mixed systems) from very early stage: - to develop institutional capacity~ - to make funding more prediclablc and sustained
Keep MNCH at core of package of benefits. Wal'ld flealth Orgul/;ul/;OI/
11",.,1 OJ
Annex 3 Scaling up coverage of child health interventions will cost US$ 52 billion over 10 years, in addition to current child health expenditure. US$ 2 billion in 2006; increasing to US$ 8 billion in 2015. An extra outlay of around US$ 0.47 per inhabitant per year initially, expanding to US$ 1.48 in 2015. Single greatest cost: human resources. World Heallh Orgtur;zmlvu
Scaling up coverage of newborn interventions will cost • Costs for 90% coverage in 75 high-NMR countries Current = 2.0 billion Additional =
4.2 billion
70% of this spending will also benefit mothers and older children
Apri/05
'" The human resources crisis Shortages after years of insufficient production, downsizing, caps on recruitment, frozen salaries, losses to migration and HIV I AIDS, social and economic crises Skill·mix mi,.mal~h, _~~;g;"fiiZiil'iliIiiii
Making up for the shortages In the next 10 years, 75 countries need: - at least 334 000 additional midwives (or professionals with midwifery skills); - upgrading of 140 000 existing professionals providing first-level care; - upgrading of27 000 doctors and technicians to provide back-up care; - deployment of 100 000 mUltipurpose professionals backed up by millions of community health workers. plus specialized referral-level personnel to scale up child health caTe activities . World lIenhil lAgutIiul/1tJ1I April 05
• __
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.... World Heakll OrgrJllizrJliQlI •••" April 05
~~ .. ,_..-..... , ........",.. __ "'_~.
_-_
...
Annex 3
REDUCING CHILD MORTALITY IN MALAYSIA Dr. Narfmah Awln Director Family Health Development Ministry of Health, Malaysia
Public Health Approach
o o o o
o
WPRO I May '05
WHY need to reduce? WHAT was the situation, WHAT is it now? HOW was this done? WHAT else ? WHAT will be the challenges? (SWOT)
WHY? Very obvious ••••••••• ~
THE SITUATION
~ ~ ~
~
Health a human right PHC, HFA (Alma Ata 1978) Universal values National development Something can be done!
HOW? 3 broad categories:· (1 )Secu lar factors (2)General health strategies (3)Specific strategies for • maternal health - child health
Secular factors Remember ...•......• (1) "New" P/health (2) PHC principles • intersectoral collaboration ~Education ~Housing ~Transport ~ Environment
~
Rural develop will
~ Socio-economic ~ Political
~Food
(HENCE MDG's
CD ... ®)
Annex 3
General health "Political commitment" to be effectively translated Principle of. EQUITY • VULNERABILITY • DISADVANTAGED applied deliberately to health Hence Ministry of Health as the main
........ invested in (1) Physical facilities (access) (2) Human resource (number & quality) (3) Strong PHC, linked to other levels (4) Quality (eg QAP) (5) EBM I HTA (6) R&D
Specific initiatives for MNCH (1) FAMILY HEALTH DEVELOPMENT
The "standard" activities • Growth monitoring • Infant & Young child Feeding I Nutrition • Immunization (added Hib) • IMel • Etc Added on • Special needs, adolescent • Prog. pregnancy care
•
Safe motherhood, HRA Referral, emergency obs. care Careful review of F/Planning ("quality" aspect) CEMD
Special attention to Perinatal and Early Neonatal:• Perinatal Manual • Training on Resuscitation • PNM Review I Audit • Neonatal Retrieval
(2) Linked to other programme
o o
o o o
Env. sanitation Medical service I secondary care Disease prevention & control Health education Support programs
Annex 3
Challenges (1) (2) (3) (4) (5) (6) (7) Law of diminishing returns Geog. remote children Emerging health problems Resources always limited Gaps in knowledge Remaining poverty Threat (If any) of He reforms, globalization, environment degradation REFORM
lOS - W - 0 - T" especially to meet the MDG's To be able to sustain is a challenge
-+ for the better
- Thank you -
Annex 3 Vietnam Area: 330.000 km2
Child health situation in Vietnam: Experiences, Challenges and Way forward
Population: 80 milian (pop.density: 2451km2) Fertility rate: 2.1 Pop. growth rate: 1.5 Children under 15: 32% Rural: 80%. Urban: 20% 7 ecological regions
Human Development Index Rank: 109/176
Epidemiology Trend of child mortality
Neonatal, infant and U5 mortality by geographic areas
I~
=-_1
rnurll11~YI ;
/= I
~---.
'"
"" I
Trend of child under nutrition 1985-2004
Child Health-Under 5 nutrition • Low Birth Weight: 7-9% (?)
r··· ~o 1 /
1-":;-1 "'-8 ~ ~,
• Prevalence of subclinical vitamin A deficiency: 12.4%
•
~
..• ,.. _.;1018 ..•_~.
:u
-...
.,)1)_7
• Iron deficiency anemia: 34%
. i '0 1 I' --,,,-,.~--,.. -. ~'--"",.----~-,,-----_~ -----------~--------~-~-~
Annex 3 Policies , guidelines National strategies for child health StrlleOY to, ,,",Ople'l .... lth "re ....:I p, OIM;tlon 2001·2010
"donal population WlleOY 2001..2010 . .1IoM1 Strat.gy on ReproduclIw hMlth 2oo1 .:t01 0 "Ilona l Str. t.gy on Nulrltlon 2001·201 D
....Ith ",. ~ bi Nd on uMffM. bI/I • • wnptlon IcIr child,.., ""dll<' Ministry of ....1111 _ !MCl dirKdve 1",
Ministry of ....l1li _ Directlw on Mwwbo,n gore 200S
....110"'1 Plan 01 Slfe Mothlmood In V'-tnam 2003 .,]010 N.lIonal Slandl, ds Ind Guk'-Ilnel on A.productlw ....1111 2003 (1nc1 .Neo. Hulth)
NaIJoNJ Ac:tIon Pilon on PMTCT 2C1K.,]01D.-oillng .ppr....1 Initiation of PoA _ ..I ....1th a nd pla n of Idlon in..", and lfOII"g child fMding
Actors Ministry of health, Reproductive health department Implementation Institutes, hospitals, medical schools Provincial and district MCH centers, hospitals, secondary medical schools (very decentralised setting) International organizations: WHO, UNICEF, WV, Plan International, EG, Danlda, SDA. AuAIDs. etc. To coordinate various stakeholders, steering committees and subgroups have been established but are not realty active
Experiences - Improvement of health worker skills IMeI: 11 day training in IMCI. 7 day course piloted
Covefage:
app. 50% d tOlal no. ri districts In 38165 provinCeS
Curriculum for MS & SMS (4/8 MS, 3170 SMS) Nutritio n :
8FC (4 days) incJuded into cvrriculum ri all SMS CFC training coverage 213 of all provnces Neona tal health: PCPNCpiloted
5 day COI.KSe In CCM"t'bnaUoo wilh Safe Motherhood (3165 provinces) Training units In KMC
Experiences - Improvement of health system IMGI : Regular supervision of vertical programs such as malaria and EPI but few IMG I activities included
Experiences - Improvement of family and community practices Many comrrunity activities carried ouI by ver\lC8l programs! projects
Protein Energy Malnutrition (PEM) program: training mothers, nutrttlon collaborators, IEC, food derronsttatlon & growth rronItoring 1999-2000: rnroduCtJOn of key family practice CCln1)CInenI: IEC
Pilot project to translate IMCI classifICations into HIS Guidelines for care al first referral level In developing countries translated into Vietnamese
materials developed by National Center for Health Education (CHE).
Comrrunlcallon training activities of VHWs in 13 prnvinces by CHE on key family pracIlces and preventiOn of Injuie$
Nutrition: BFHI started in 1995, in 2004: 54 provincial and central hospitals BFHI. Reassesment has not be done for 6-7 years
2003: C-iMCI revtew: development of C-tMCI TG, Work plan C-tMCI and Indicators C-IMCI
Annex 3 Challenges Lack of continued coilaboratJon vertical programs and organizations implementing IMGI. nutrition and neonatal healthl safe motherhood
Way forward MoH to improve collaboration within chUd health Priorltise disadvantaged areas Prloritise neonatal health care (including neonatal screening) Development of national standards and guidelines in child health
Vertical introduction of BF. CFC and IMel into pre-service DiffICUlties for progmms to reach remote areas Recent direction to put neonatal health higher on agenda
care Strengthening regular integrated supervision Focus on pre-service education Encouragement of provinces to improve child health by receiving support from central level in planning, resource mobilisation, implementation of activities etc. Improvement of role of families! communities in child health
Lack of understandtng and
i~menting
of exclusive SF
No proper 8FHI continuation and reassessment Practical part of training course not always up to the standard
No adequate follow-up after training ( IMGI: only 45% of CHWs) Struggle for provinces to continue supervisory activities without budget
Annex 3
Infant and US mortality by year 1990-2003 Health and Nutrition
Dr Gochoo So)Olgerel 0t!Icer tor ChIlO ....:l AdoIeicent Hellllh MInistry 01 Health
Moogolia
Thanks
ANNEX 4
Highlights of the WHO-UNICEF Child Survival Strategy
-
'Wfiat wouU tfie worl4 6e ali.! witfiaut tfie SDUM
DR LINDA L. MILAN DIRECTOR Building Healthy Communities and Populations WHO, Western Pacific Region
af cfziUren pfayi"l1?
._1 _}! lPossi6iCity. .._~: : . ~,-
~ - 1 -
CfiiUf mortaCity, sefectetf countries ('WP1()
"-
,
~
11 M children globally die each year before reaching their 5'" birthday Ca th ird of these in South Asia)
. ". ... no
---
!
~
3000 children < 5 yrs die each day in the Region
"
",
:Ml
• • f-ff+l1l
Child Survival Interventions • Ctwp l . GrooI$I2 GrWlIl
C.u .... I>.:1f1c l>,o ~lio".1 mo,tIoI lty . WPA HIli" mottaU\y eountrl. . · 2OOO-2OOJ
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.
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-
Annex 4
--:b '1Jie Strategy: 06jectives Improve access to and utilization of the essential package of child survival particularly in areas of greatest need '" Provide an enabling environment for child survival where financial and human resources match the burden of disease N Reduce inequity in (Nld survival across the region, both between countries and between population groups in countries tv
-:I:
'l1ie Strategy: Strategic IPrincipCes - Emphasize a positive policy environment for C5 - Maximize health system capacity for C5 tv Engage families and communities to promote C5 - Ensure joint efforts among all programmes contributing to C5 - Collaborate closely among CS stakeholders
_1 _'1Jie Strategy: Sn:ategic Components "'~ ~
-:I:
'Essentia{ Pac{ll[Je for CliMSurviva{ ... SkIlled attendance during pregnancy, childbirth and ~ Immediate postpartum period with essential ne.'bom care and care d the sick newborn - Exclusive breastfeeding fa 6 months, adeqt.8te and safe complementary fEf!djng from 6 rronths onwards with continued tnastfeedlng and micronutrient supplementaUn '" Vaccination against vaccine preventable dlseses
Evidence-based interventions essential Package for CS Enabling environment for CS Reducing inequity in CS Monitoring and evaluation
~ ~ ~
... case ma~ment 01 pneumonia ... case ITIaI'lag!!ment ofdlarriloea ... Use of Inse::tidcle treated bed nets and ~ treatment of malaria where indicated ... Prevention of Mother to OIild TransmiSSion II HIV
-:I:
'Ena6liTl{J 'Environment for cliira Surviva{ - Increasing financial and human resources for child survival - Improvement in water, sanitation and the environment - Promoti ng gender equality and empowering women - Birth Spacing
-!
,%cCuciTl{J Inequity in CliiraSurviva{ - Aim to reach the poorest and most marginalized households of the society ~ Universal coverage of child survival interventions where a high concentration of low-income households - In other countries/ areas, a targeted approach to reach the poorest households
Annex 4
-:J- CliiUSuroiva{ Core lruficators (1) ~- Proportlon or: N
i
CliiUSuroiva{ Core lruficators (2) Proportion of: .... under-weight children under five years of age
babies exduslvely breastfed for the first 6 months weeks who received medical care diarrhea cases In the last 2 weeks who received ORT 1· yr old children Immunized against measles deliveries assisted by a trained attendant children < 5 yrs In malarious areas sleeping under an Insectldde-treated mosquito net
.... children with fast or difficult brea thing in the last 2
... '" .... ....
.... infants 6 -9 months receiving breast milk and semisolid food .... children 6-59 months receiving one dose V1t:amln A In the past 6 months
... pregnant women who receive at least two n Immunizations
.... households with access to clean wat er ... households with access to sanitary latrines
'ffiant
ry'OU/
Annex 4
Essential Package for Child Survival Techn ical Consultation on the Ch ild Survival Strategy II... _ _ _ • • H _ ..... " _
• To review the development of and rationale behind the components of the essential package for child survival. To give a brief preview of how it can be used.
Or. St. phen J. Atwood
UIIICEF E....... 1......
1'''''' It ......",
--... . ~
""' ...... "..... ........ ''''''''''''''' "(_lin' H_~.....-.£
Ail'lANtt
unicef.
unicef.
To improve access to and utilization of the
essential package of cHild survival particularly in areas of greatest need To provide an enabling environment for child survival where political will, financial and human resources match the burden of disease To reduce inequity in child survival across the region, both between countries and between population groups in countries
Emphasize a positive policy environment for child survival Maximize health system capacity for child survival in the region Engage families and communities to promote child survival Ensure joint efforts among all programmes contributing to child survival Collaborate dosely among child survival stakeholders
unicef.
unicef.
The Lancet Series 1 (2003):
lil
- eldensNely f"fMewed key chld sllfVlvaJ interventiOns. - estimated that two-thirds 01 chid deaths CDUId be
rr:=~~liain:::a=s~d~alit~":'
off!:tvenled by
s/f8ng/11 d
The basis for an Essential Package unicef.
The Lancet Series 2 (2005): lJfl - 161n/efVentiOtls with proven effICaCy for neonatal sutWva/
- In areas with flipII chid moriality, high coverage with a selected
subset 0/ these Inlerventions cie/ivered /hrourih en essen/lal package could substantially reduce neonatal and child mortality. Uincflt 2003
Ol/ Nflwbom health: a kay 10 child stllViVilJ. LMcel 2005
mThe BeI1agk/ Child Survival Group.
unicef.
A nnex 4
Dewormlng of children < 5 years old . In'ipoftMIt. but mote for I'IlIIritItlnII effecllhan dlikl sur.t.'aI
Deworming of pregnant women - One study shows .1 % reductiofI ln Infant dea ths at 8 rnonth5.
Strengthening birth spacJng Interventions; - ChIcHn born 3-5 )'ears -'tef a ~ bWI . . aboIA. 2.S *nell lIlOfe hllely 10 sLrVtve hlir inl8ncy than children bom ellflier.
Reducing fertility; preventing adolescent pregnancies. - M05llmponant lor reducing maternal mortality, 1ndirec1 effect on ctlIld
• A clear, essential package that is within the capability of every govern ment to deliver. • Based on solid - and accepted evidence. • Able to be monitored and evaluated in it's use - and adapted according to local epidemiology.
ITIOftaIlty (although adolescenb I n sH" children),
Improved access to water and sanitation. - Part of the 0enebllng erwrormenr , a mtJ5t as .., oodertyIno cause 01 ~ and)'OU1l
chid IT'O'tIIiIy ~ morbidity.
.101.,_
unicef. "
unicef.
..
For WHO/UNICEF: - make sure it is available to every child in worst-off countries [Group IJ; - target it geographically to underserved areas in transitional countries [Group 2]; - target it at the socio-economically underprivileged and marginalized in 'developed ' countries [Group 3J
Ultimately, it's the right of every child
unicef. "
.101.,_
unicef. . .
. -_-
- - --
--
"
Annex 4
2. Service Delivery ..... . 4 Effective use of health service delivery points for child survival • • • • • • Ante-natal care visits Birth attendance Post·natal visits Immunization sessions Well child visits Consultations for sick child
3. Families and communities 1 Improve appropriate home care for the child 2 Timely health-seeking behaviour 3 Active community involvement in health promotion
Health systems issues • Private sector • Increasing part of every health system • for pharmaceJticals, s~plies, equipment • as service providers, for-profit and not-for-profit • external driver: WTO
• Private sector (2) • lack of effective regulat Ion - consumer safety • • • • • registration/licensing s)6tems disciplinary processes agreed profeSSional ethical standards user-friendly canplalnts processes effectively implemented prodwrt safety legislation (drugs, deViCes, consumables) + counterfeit action
• little understanding of what private sector is or does • unbalanced Influence and conflicts of Interest • misunderstanding about 'control'
• other mechanisms • professional associations - very few • leverage through pLblic funds/subsidies - v. limited • public information
Health systems issues (2) • Primary health care • The PHC approach encompasses the following principles: • Equity
• Community Involvement/participation
• Intersectoral collaboration - --;,~ ..", technology • Affore.:..irl(; costs
• Conceptually - what is it now? • a philosophy, astrategy, a level of care, a set of actions?
• Perception of failure of PHC • Should more be included about PHC 7
Annex 4 Country grouping to respond to diversity • Improve adequacy of interventions because of changing profile of child mortality -Improve the feasibility of implementation by tailoring strategies to local problems and constraints ~
Criteria and process of country groupIng Koen Vanormellngen UNICEF, China
Improve global equity by focusing on inter-country disparity reduction
• Improve effectiveness of advocacy, leveraging. partnership building and fundraising • Improve monitoring of achievements by tailoring targets to countries Improve exchange of experiences between similar countries
4
Criteria of selection L_, HlgM' National Child Mortality Rat.. Neonlltal Mortality;lls proportiDn of Iotal USMR
Higher HlgMr
•
L....'
Prevalenc. ofmalnutrttion (stunting)
'-L_ Higher StTono-r
Propoc1ion of home . .!wrie. Proportion of children's In totIIl pop.Uon
......
HI".r '-
...
A&::cuII to""'.nd Nnbdon Hulth system dewtIoprNrd RnourG1J5 ("neMlI.nd human)
L....' Fl'1Iglle Vary limited
Lim"""
Better-off countries
Worst-off countries
:,.--
Source: sowc. Dev]nfo. DHS
Neonatal Mortality as a proportion of U5MR
I I , I
60
Prevalence of Malnutrition (Stunting) .............................•...... -.. -........... -............ -......... _._-_.
C.u....pectic prnpol"tlona' mort.Mty In low mor1811ly countrIU from Wpr. 2000.2003
•
-1
1990 19911992 199319941995111& 1"71. 1_ ZOOO 2001 ZOO2 2003 2004 ...... Aostraia
-cambodia _Malaysia Phlippines
C"'" -·Jvbrgolia
-PORLao Papua New Gunea .~.-
-+- Sin;apore
Source: UNICEF EAPRO, Collntty iUt"VCVS (MICS, DHS, NHS, elc.. )
Annex 4 Proportion of facility deliveries (selected countries) 120 100 80 60 40 20
.:: ~
· · · ~
>
0
--.~
--
Process of selection of countries - Coliation of indicators: U5MR, IMR, MMR, undernutrition rates, access to water and sanitation, other." -Tentative listing: worst-off, transition, better-off -Validation by nominal group by UNICEF representatives use one or two countries as reference points and relative ranking Reconciliation difference between two listings
Country Groups: a region in transition Group 1: worst-off: infectious diseases and undernutrition prominent throughout the population, low GDP Group 2: transition: rising proportion of neonatal deaths and unintentional injuries inaeased GDP and mid range development indicators - BUT some populations like Group 1 Group 3: better-off: nearly complete transition, fewer (neonatal) deaths, proportional increase of injury, congenital an dgenetic abnormalities; some underseryed or unregistered populations
·Ma rshaUlslands: worst-off: decrease US support ?
Classification of countries
Interventions in countries • Group 1: - Essential package for child survival - Oeworming of pregnant women and 6-59 m old children
·Group 2: Geographic targeting of Essential package Comprehensive newborn care - Prevention of childhood injuries - New or underused vaccines
• Group 3: - Social and economic targeting of Essential package - Hospital deliveries and comprehensive newborn care
- ~~on of childhood safety
- "1tfew or underused vaccines
Annex 4
The way forward How to Implement the child survival strategy In countries
Organize and mobilize for child survival?
3 one's and 2 M's for child survival? 3 plus 2? • One effective coordination mechanism with suffICient authority to lead all stakeholders • One integrated national plan for child survival • One national M&E system measuring core child survival indicators
• Mobilize all sectors of society through a communication and advocacy strategy • Mobilize sufficient resources to accelerate implementation and sustain progress in the long term
--
ANNEX 5
GROUP 1 (1) Skilled attendance during pregnancy, childbirth and the immediate postpartum period with essential newborn care and care of the sick newborn
In this component the focus is on skilled birth attendants, family and community care, and antenatal! and postnatal care including outreach for low birth weight infants25 . 1bis will require: • Community care: Community mobilization and engagement, and antenatal and postnatal behaviour change communications to promote evidence-based neonatal care practices (breastfeeding, thermal care, clean cord care), care seeking, and demand for quality clinical care, promotion and practice of clean delivery and referral of complications (for home births) • Antenatal care: two doses of tetanus toxoid immunization, screening and treatment for syphilis and bacteriuria, pre-eclampsia and eclampsia prevention (calcium supplementation), intermittent presumptive treatment of malaria, counselling on breastfeeding; referral in case of complication [Need to review these antenatal care interventions and apply the same rules of inclusion, i.e. that they are effective in improving child survival. low cost and can be brought to universal scale, or leave the details of what constitutes ANC out of the essential package description. ? evidence behind calcium supplementation to prevent preeclampsia, ? need for addition of iron and folate supplementation (although it would be necessary to give folate pre-pregnancyl] • Skilled attendant at birth: labour surveillance; encouragement of supportive companion, neonatal resuscitation • Postnatal visits and extra home visits of low birth weight infants; support for breastfeeding, thermal care, and hygienic cord care; early recognition and care seeking for illness • CommuDity based eCase management of neonatal pneumonia and DeoDatal sepsis: detection of neonatal pneumonia and sepsis; treatment with antibiotics The group felt there was a need to delete "Communitv-based", as antibiotic therapy for neonatal sepsis can be applied effectively at health facilities also.
(2) Exclusive breastfeeding for six months, and adequate and safe complementary feeding from six months onwards with continued breastfeeding and micronutrient . 24 suppI ementatlOn
1 Note: Antenatal care wiIl not support the woman around conception and in the first trimester, two periods now considered critical for prevention of birth defects and of significance in prevention oflow birth weight and short stature. A pre-pregnancy visit is suggested to guarantee the health and nutritional weIl-being of the woman throughout pregnancy.
Annex 5
There must be improved infant and young child feeding practices with exclusive breastfeeding «6 months), continued breastfeeding (6-23 months), and complementary feeding from 6 months onwards and Vitamin A ImcreHtltrieE:t supplementation fer the child '.vith VitamiR A, 6 monthly from 6 to 59 months.
(3) Vaccination against vaccine preventable diseasei 4 Vaccination with wiih-measles vaccine, tetanus, diphtheria, pertussis, polio and BeG vaccines for the child are part of the routine BPI schedule. In some countries Vitamin A and deworming are delivered together with immunisation. Add polio vaccine. (4) Case management ofpneumonia 24
This requires antibiotics for pneumonia and Vitamin A supplementation of children 6 monthly, from 6 to 59 months. wee days of antibiotic therapy with oral amoxicillin or cotrimoxazole should be used in children aged 2 months up to 5 years. Where antimicrobial resistance to co-trimoxazole is high, oral amoxicillin twice daily is the better choice.
The group suggested to leave out duration of treatment for pneumonia, as the evidence for 3 days only applies to non-severe pneumonia. Vitamin A is not part of case management of pneumonia, although many children who present with pneumonia (and many other conditions) will be due for vitamin A as part of routine supplementation.
(5) Case management of diarrhoea 24 This requires oral rehydration therapy with hypo-osmolar oral rehydration solution (ORS) along with zinc 20mg per day (10mg per day in children from 6 te 9up to Q.months) for 10-14 days. Antibiotics are indicated for dysentery only, with ciprofloxacin being the most appropriate drug. Exclusive breastfeeding, continued breastfeeding and complementary feeding in children from 6 to 9 months should be continued during diarrhoeal illness.
(6) Use of insecticide treated bed nets and prompt treatment ofmalaria 24 In malarious areas, antimalarials should be administered promptly and insecticide treated materials used for children with antimalarial intermittent preventative treatment in pregnancy. In most countries, artemisinin-based combination therapies have been shown to improve treatment efficacy and are administered as artemisinin based combination therapy.
Annex 5
(7) Prevention ofMaternal to Child Transmission ofHlr?4 Most countries in the Region, have an increasing problem ofHIV/AIDS. These countries must be supported to address prevention of mother-to-child transmission (PMTCT) of HIV. The four pillars of PMTCT include primary prevention, voluntary counselling and testing, prevention of mother-to-child transmission, and care and support for HN positive mothers. In areas where HIV is a significant public health problem all women must be assured access to confidential testing of HIV. If a mother is HIV -infected and when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding is recommended. Otherwise, exclusive breastfeeding is recommended during the first months oflifei . Nevirapine and replacement feeding for 24 HIV positive mothers, where available is an evidence-based intervention . 8. Familv planning and birth spacing. The group felt strongly that Family Planning and Birth Spacing should be included in the Essential Package, as this has demonstrated effectiveness in reducing child (and maternal) mortality, is cheap, can be brought to universal scale. and enhances equity.
10.2
Interventions for Group 2 Countries
Priority interventions for Group 2 countries are to be targeted at the most difficult to reach communities, that is those areas of the countries with the "Group i-like" profile. However, in some of the Group 2 countries, there will be rational arguments for pursuing transitional approaches, outlined below, directed at sometimes more costly interventions and at non-communicable causes of death. • Improvement in comprehensive perinatal and neonatal care • Promotion of childhood injury prevention • Referral care Introduction of new or underused vaccines: rotavirus, conjugate pneumococcal vaccine, Haemophilus influenza type B and Hepatitis B
Enabling Environment for Child Survival Creating an enabling environment for child survival involves actions beyond child health programmes. It is embedded in the efforts of complementary areas in health and other sectors such as education, financing and those sectors pursuing development goals. In order to effect the necessary improvements in the environment inter-sectoral collaboration is required. 7.1 Increasing financial and human resources for child survival
Massively increased investments in child health will be required through increased government spending and external assistance. There are staggering shortages and imbalances in the distribution of health workers with the knowledge and skills to perform child survival activities. Insufficient production,
Annex 5 downsizing and capping of existing health workers through health sector reform policies and losses to the private sector and through migration are major challenges that need addressingii. 7.2. Improvement in water, sanitation and the environment
Increased access to safe water supply with increased quantity of water for personal and environmental hygiene and improved sanitation with safe disposal offaeces are important to realize MDG 4. Additional actions to create safe home and community environments, free from indoor and outdoor air pollution (including solid fuel use) and good food and personal hygiene will augment the essential package for child survival.
7.3.
Promoting gender equality and empowering women
Gender gaps are widespread in access to and control of resources, in economic opportunities, power and political voice. Promoting gender equality is an important part of any development strategy that enables both women and men to escape poverty and improve their standard of living. Economic development paves the way for increasing gender equality in the longer term however this must be coupled with an environment that provides equal opportunities for women and men and policy measures that address persistent inequities. Evidence has shown that empowering women through education is likely to benefit their children lll • The graph below shows that child immunisation rates rise with mother's education. i
WHOIUNICEPIUNFPAlUNAIDS. HIV transmission through breastfeeding: review of available evidence. 2004. WHO, Geneva. World Health Organization. The World Health Report 2005. Making every mother and child count
ii
iii
The International Bank for Reconstruction and Development. A World Bank Policy Research Report. Summary Gendering Development 200 I
The group felt there were good arguments for including some interventions in the "Enabling Environment" (particularly water and sanitation, and female education) within the Essential Package, partly to emphasize that non-medical interventions are necessary to reduce child mortality. However we accepted that there is a need to limit the number of essential interventions. Another area thast the group felt should be emphasized more fully in the document was referral level care. The group noted that there was nothing in the document about case management of malnutrition, despite this condition being associated with >50% of child deaths globally.
Annex 5
GROUP 2
Working group on three target areas Participants: Dr Dai Yaohua, Dr Chris Morgan, Dr Tadatoshi Kuratsuji, Dr Elizabeth Rodgers, Dr Rornanus Mkerenga, Dr Din Ti Phuong Hoa The group reviewed section 11 strengthening child survival actions
Suggestions for overall structure Foreword Exec summary Background Rationale Situation anaZvsis Health care financing Financing data 1. Essential package M&E for essential package 2. Complementary interventions/underlying causes 3. Create enabling enviromnent for child sUlvival Strategic approaches for child survival 1. Create enabling policy environment
One coordination mechanism • 11.1.1 Governance and leadership issues a Acknowledge different groups exist with different mandates relative to child survival (maternal health, nutrition, BPI) a Acknowledge a range of theoretically complementary policies exist a Address legislation a Move 11.1.1 last para ("Child health .... Strategy Papers") to planning section a Insert first para 11.1.2 ("Leadership ... agenda") here • 11.1.5 Strengthen partnerships in child survival o Address private sector Olle plan
• •
•
Insert last para 11. 1.1 here Insert 11.1.3 strengthening planning ... o Move second 11.1.3 para ("Child survival data") to M&E section a Address cost of essential package a Insert 11.1.4 budgeting for cost effective interventions Insert 11.1.4 para "human resources"
Annex 5
One M&E mechanism • Insert 11.1.3 para "child survival data" here • Address supervision and feedback • Address quality assurance Resource mobilization and financing • Insert 7.1 "Increase financial and human resources for child survival" here • Insert 11.1.4 second para "increased allocation of financial resources" here and change "allocation" into "mobilization" • Insert 11.1.4 fourth para "social health insurance" Advocacy • Insert 11.1.2 para "Advocacy and communication" here
II. Improve quality and access (what the MoH can control) Integration for quality and continuity of care Appropriate service mix for access and effectiveness Targeting for equity Demand generation III. Empower families and communities (what the MoB can influence)
Annex 5 GROUP 3 Equity Guiding Questions: Does the strategy adequately deal with disparity and equity? Yes and No Yes: - because disparity is cited as one of the rationale for the strategy - equity is one of the three objectives ofthis strategy - the grouping of the WPRO countries into 3 groups is based on disparities among the countries No: because in Chapter 8 it does not deal with equity because it does not give enough guidelines on how to deal with inequity except to give very broad statements. There are no indicators for measuring and monitoring equity How could the strategy be better in addressing inequity: What is the role of the health sector in ensuring equity in CS? make clear policy on equity at all levels take leadership in ensuring equity implement the policies measure to advocate to other sectors set standards of quality care How can new and existing national strategies and policies ensure equity in CS "mainstream" equity and 'child' in whatever policy How to monitor equity? measure resource allocation by relevant parameters ($$, manpower, facilities) o geographical o socioeconomic o ethnic/indigenous o gender o others measure trend of cost/fees charged for child survival services (should be free of charge) service utilization by children by the 3 or more parameters above country-specific approaches targets should be made for the poorest (bottom 20%)
ANNEX 6
Child Survival Core Indicators 1. Proportion 01 babies excIusN8Iy breaslfed for the (11"516 rrcnthS 2. Proportion of children with fast or difficult breathing ~ the 18$12 weeks who received medical care 3 . ProportIOn of diarrhOea cases in the 1as12 weeks who received CRT
Monitoring, indicators, equity
4. Proportion of of~:eed to standardize with :E s. Proportion nl :mea,.. S. _ " MICSlDHS surveys ...... under an inSectiCIOli"lle<:llt!U IIt.lSQtlltU11tl1 7. ProportIon of under-weight children U"Ider five years of age 8. Proportion of Infants 6-9 months receMng breast mill and semsolid food 9. PropatJon of Children 6-59 months receiving one dose VItarm A in the past 6 months 10' ~~:regnanl women who receive at least two TT
Mlnlstert.l Stlllmlt on...,1UI IluMrdl
Child Survival Core Indicators Population-based survey - MICS, DHS, etc Repeated at least every 4-5 years - If possible more often
"'-"lc:o City. M..k o _ "",-",-1140, 2004
The research-policy dialogue 20 years' experience in Ceara State, Brazil Jocl~
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Annex 6 Text - Figure 2
How to express inequities Classify population into socioeconomic groups (usually qUintiles) Calculate: - Rich/poor ratio • BeG coverage is 1.8 times higher among the lich
USE OF HEAlTH SERVICES BY BOnOM AND TOP WEALllf QUINTlL.£S IN
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Annex 6
Requirements for acceleration of child survival in WPRO
Approaches to improve child survival actions Technical consultation on the child survival strategy Manila, 12 May 2005 R. Scherpbier Medical Officer, CAHlHQ
• Focus: simple message to attract donor funding • Diversity: strategic support to countries to accelerate child survival • UNICEF & WHO Joint Strategy 2006·2015
Addressing the focus: to be resolved • SMART package (+ indicator set) - Revisiting component 1 - Consistent specification of interventions throughout the document Clear statement of the problem - HR at country level? -$? $:
Proposal Low klcoma cDuntrles mlilt spend more .nd pricriliM lUdtIng the poor
Donor countriloa must Sf"'- mort! and " " this tMrtter ta str.ngllwn ... 1th .ys"
-
People: HR plan for priority countries
Addressing the diversity: to be dealt with • Strategic support to countries to accelerate child survival .J Country grouping 1, 2, 3 .J SMART package 1 (+ indicator set) - Packages for groups 2 and 3 - Delivery channels
Low income countries must spend more and prioritise reaching the poor
Annex 6 Donor countries must give more and use this better to strengthen health systems
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Annex 6
Indicators Also needed - indicators: Preliminary list Need to ensure compatibility with MICS/OHS Mortality Malnutrition Equity (wealth, sex, etc)
Cesar Victora
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