DPGH Retreat Protea Courtyard Hotel, 04 October 2017 Reproductive, Maternal, New-born, Child and Adolescent Health: Past, Present and Future DPGH Retreat Protea Courtyard Hotel, 04 October 2017

Presentation Outline Background of RMNCAH in Tanzania Government’s Approach to RMNCAH 1. Align all Partners behind a Single Plan 2. Focus on Results 3. Use an Integrated Service Delivery approach to RMNCAH RMNCAH Coordination Platform in Tanzania Challenges The Future

Demographic Information Selected RMNCAH Indicators Indicator Data Source Total URT Population 50.1 million NBS 2016 (projections) Young people aged 10 – 24 14.4 million (32%) 2012 census Population aged 0-14 19.7 Million (44%) Total Fertility Rate (TFR) 5.2 2015/16 TDHS Maternal Mortality Rate (MMR) 556/100,000 Skilled Birth Attendance 64% Antenatal care (first ANC visit) 98% Neonatal Mortality Rate (NMR) 25/1,000 Infant Mortality Rate (IMR) 43/1,000 Under Five Mortality Rate (U5MR) 67/1,000 CPR (modern methods) 32% Unmet need for FP 22% Teenage pregnancy rate(15-19) 27%

Reproductive Health One Plan CPR Goal = 60% by 2015

Child Health

Maternal and Neonatal Health

Causes of Death

HSSP IV and within that BRN in Health Policy Environment HSSP IV and within that BRN in Health One Plan II Health Policy (2007) prioritized RMNCH services (under review) RMNCAH services built on the HSSP IV which implements Health Policy Sharpened One Plan 2014-15 launched together with the RMNCAH Score Card in May 2014 One Plan II 2016-2020

The One Plan II MISSION: To promote, facilitate, and support in an integrated manner, the provision of comprehensive, high impact, and cost effective RMNCAH and nutrition services, along the continuum of care to men, women, newborns, children, and adolescents KEY AREAS OF FOCUS: Re-defined FP within the broader RMNCAH context Care at birth, Post Partum and PNC (HRH - Skilled health care providers) Commodity Security Prioritized Adolescent and youth SRH services KEY STRATEGIES: Strengthen reproductive, maternal, newborn, child, and adolescent health Scale-up the child health program Strengthen response to cross-cutting issues, e.g., commodities, community involvement, demand, HMIS

Government’s Approach HSSP IV and within that BRN in Health One Plan II Government’s Approach Align all partners behind a Single Plan All partners are obliged to implement “One Plan II” (2016-2020) Through SWAp arrangement Planning and Monitoring done by RMNCH TWG Constitutes the Investment Case for the GFF for Tanzania

Government’s Approach Strong Focus on Results There have been significant achievements over past decade … WHAT WILL DRIVE THE NEXT SET OF GAINS? Government increasingly focused on Quality of service delivery, Results and getting Value for Money Hapa Kazi Tu! DPs support to government increasingly results-oriented Entry points for performance-based initiatives Star Rating Assessment Results-based Financing LGA Scorecard Regional Scorecard National Scorecard

Government’s Approach Use an Integrated Service Delivery Approach to RMNCAH Performance-based initiatives are all focused on RMNCAH-related indicators or factors affecting RMNCAH service delivery: Examples; 1. Star Rating Assessment with focus on Quality of care 2. LGA Scorecards 3. Results-Based Financing (RBF) Star Rating Assessments

RMNCAH Coordination Platform in Tanzania Development Partner Group (heads of agencies) DPG-Health DPG-Nutrition DP Coordination Mechanisms Health Basket Fund Steering Committee Results-based Financing Steering Committee Coordination for Funding Mechanisms RMNCAH TWG Sub-TWGs Family Planning RH Commodity Security Safe Motherhood Adolescent RH Newborn and Child Health RH Cancers PMTCT Immunization and Vaccines Gender RMNCAH- specific TWGs Health Financing Health Commodities and Technologies Human Resources for Health District, Regional, Zonal and National Health Services Public Financial Management Public Private Partnership Social Protection and Nutrition Other TWGs Technical Working Groups Several donor coordination mechanisms exist in Tanzania, and it was purposely decided against establishing new GFF-specific coordination mechanisms. Technical Working Groups are co-led by Government and DPs. Some TWGs are RMNCAH-specific as shown here are. Others has indirect links with the RMNCAH agenda. For example, Health Commodities, Health Financing etc. The new financing mechanisms also have coordination structures that comprise Government and DPs. These are led by the Ministry of Health. Examples include: the Health Basket Fund Steering Committee and the Results-based Financing Steering Committee, both chaired by the PS-Health.

(mostly related to service delivery) Human Resource for Health Key Challenges (mostly related to service delivery) Health Facilities 1 Barriers to healthcare goals: healthcare infrastructure, equipment; health worker coverage/distribution, decentralisation of health system, procurement bottlenecks Poor quality of healthcare at all levels. Performance and efficiency of the forecasting, procurement, quality control for drugs and vaccines are inadequate Barriers to access: long travel distance, lack of transportation and unfriendly services Referral system has serious challenges including limited number of ambulances; unreliable logistics and communication systems Service Delivery 2 Widespread shortages (~ 50% - 70%) of qualified staff exist at all levels; esp. rural areas Staff shortages exacerbated by increasing burden of disease (esp. NCDs) Human Resource for Health 3 Health Financing 4 Budget execution Financing Gap Data 5 Data completeness, consistency challenges; significant improvements in recent years. Further improvements will arguably only come from improved use – e.g. accountability for results and as the basis of disbursements.

Other Challenges: 1. Teenage Childbearing Teenage childbearing appears to be rising and contraceptive use among married youth remains low Percent currently married women age 15-19

Trends in Teenage Pregnancies, 1999-2015 Rural adolescents continue to experience pregnancy nearly 1.7 times the rate of urban adolescents. The gain made towards reducing adolescent pregnancies that was observed between 1999 and 2010 in urban areas has been lost, with adolescent pregnancy rates increasing substantially in both urban and rural areas. In 2015, the national adolescent pregnancy rate had increase nearly 4 percentage points from 2010 to about 27%.

Other Challenges: 2. Nutrition Status in Under-five children

Other Challenges: 3.Coverage and Equity Family Planning Care at Birth Bars represent Inequities by urban/rural residence Care at birth services too low – 50% deliver in a facility with large SES inequity of 56%. Less than half of pregnant women receiving 4+ ANC (yet almost universally receive1 ANC visit showing a missed opportunity). Only 31% of women receive PNC within 2 days. Coverage for FP (demand satisfied) remains low at 46% and large SES inequities (22%)

Our Journey … 2016 to 2020 GFF Investment Case 2008 2010 2014 2013 Sharpened One Plan 2014–2015 GFF Investment Case 2008 2010 2014 2013 High impact interventions Lowest CPR in Lake and Western zones NFPCIP Mid-Term Review One Plan Mid-Term Review Maternal, Newborn, and Child Health Family Planning Our Journey … Reproductive, Maternal, Newborn, Child, and Adolescent Health London Summit and FP2020 Commitments Prioritize and scale MNCH high impact interventions Better incorporate family planning NFPCIP 2010–2015 Updated NFPCIP 2013–2015 One Plan II 2008–2015 2012

Where do we want to go?.. MMR SBA NMR IMR U5MR CPR SDPs providing YFS Strategic Indicator 2015 Status 2020 Target MMR 410 per 100,000 LB (now 556) 292 per 100,000 LB SBA 64% 80% NMR 25 per 1,000 LB 16 per 1,000 LB IMR 43 per 1,000 LB U5MR 67 per 1,000 40 per 1,000 LB CPR 27% 45% SDPs providing YFS 30% Teenage pregnancy rate (15-19) TBD

What need to be done… Alignment and harmonization by DPs on our support to improve ; Quality of care for RMNCAH Reduce inequities Health system support for delivery of RMNCAH interventions Strengthening RMNCAH health information system within the Broader health information system and health data collaborative for tracking progress and accountability Strengthening health system to deliver the recommended interventions Resource mobilization Strengthen Coordination mechanisms through TWGs and TC SWAp Strengthening Evidence based planning especially MPDSR 7. Innovative approaches

Opportunities…. Availability of Integrated RMNCAH strategic plan and HSSP IV Commitment from Partners Availability of evidence based guidelines