Zambia Accelerating progress in saving women, newborns and children Dr. Joy Lawn MB BS MRCP (Paeds) MPH PhD Director Global Evidence and Policy Saving Newborn Lives/Save the Children DFID Senior Research Fellow, Newborn Health Countdown Country Working group Co Chair On behalf of the Countdown Coordinating Committee #CD2015

Country progress in reducing maternal mortality (MDG5) Countdown to 2015 report 2012, Figure 1,progress as of 2010 Bangladesh Bolivia Cambodia China Egypt Eritrea Lao People’s Rep Nepal Vietnam All are African countries

Country progress in reducing under-five mortality (MDG4) African Countries Eritrea Liberia Madagascar Malawi Countdown to 2015, report June 2012, Figure 3, progress as of 2010 All are African countries 28 are African countries

Evidence base Increasing, mainly from Asia, Cochrane review Policy change More countries have a policy for mother and newborn home visits Still gap in coverage on continuum of care, and also a data gap And many implementation research questions especially in Africa Pregnancy and Postnatal Home Visits Lancet paper of the year Joint Statement by WHO and UNICEF, co-signatories of Save the Children and USAID

Who is Countdown? A global movement since 2005 of 1.Individuals: Scientists & academics, policymakers, public health workers, communications experts, teachers… 2.Governments: RMNCH policymakers, Parliamentarians… 3.Organizations: NGOs, UN agencies, HCPAs, donors, medical journals… Linked to Global strategy for Women and Children and Commission on Information and Accountability And from countries

Zambia’s Countdown profile 2012

Mortality and MDG progress Countdown to 2015 Report

Leading causes: Neonatal – 29% Malaria – 13% HIV/AIDS – 10% Pneumonia – 13% Diarrhoea – 9% Undernutrition is an underlying cause of child deaths (note this estimate is country specific for Zambia) Cause of neonatal and child deaths Countdown to 2015 Report

Leading causes: Haemorrhage – 34% Hypertension – 19% Understanding the cause of death distribution is important for program development and monitoring (note this estimate is for Africa, not country specific) Causes of maternal death Countdown to 2015 Report

Variable coverage along the continuum of care BUT only measles immunisation at high coverage Countdown to 2015 Report

Maternal and newborn health Limited progress for scale up of skilled care at birth – especially compared with neighbours Countdown to 2015 Report

Maternal and newborn health High coverage of ANC 1 – but what about ANC 4 and coverage of effective interventions in ANC? Countdown to 2015 Report

Other maternal and newborn health indicators

Review and Mapping of initiatives in Maternal and Newborn Health in Zambia

Background Maternal Mortality in Zambia

Data: UNICEF 2007 ( based on a subset of 80 countries with trend data Ref: Lawn JE et al IJGO 2009 slow progress in trends for births with skilled health personnel (1995 to 2008 with projections to 2015) By 2008 only 13 of 68 Countdown countries had increased skilled attendance by >10% in the last 20 years Rapid change now in many countries

Equity The narrow bars show Zambia’s relatively equitable coverage found for many coverage indicators with exception of skilled birth attendant, where almost all the richest women have access but only 1 in 5 of the poorest women Countdown to 2015 Report

Continuum of Care

Variable coverage along the continuum of care BUT only measles immunisation at high coverage Countdown to 2015 Report

Leading causes: Neonatal – 29% Malaria – 13% HIV/AIDS – 10% Pneumonia – 13% Diarrhoea – 9% Undernutrition is an underlying cause of child deaths (note this estimate is country specific for Zambia) Cause of neonatal and child deaths Countdown to 2015 Report

Survey results 116 completed surveys Across all districts

Vacancy rates

Use of Best Practice

Source of best practice

Partnerships NGOs/CBOs Number of survey respondents INGOs

Donor Sources OTHER Other: 27% smaller; 18% of projects from larger INGO such as Plan, Save the Children World Vision or ZISSP; 10% GRZ: MOH or MCDMCH ; 4% by JICA ;3% CDC and 3% PEPFAR; 2% each from UNICEF, EU and ZNAN. B&M Gates foundation; CORDAID; DANIDA; Irish Aid; NZAID. 4 communities and 4 private partners.

Monitoring and Evaluation M&E plan in place Baseline conducted

Types of interventions based on the continuum of care

Focus of training programs

Project surveyed continuing after 2012

Not all countries are the same Malawi is on track for MDG 4 Source: Zimba E et al Malawi: a decade of change, HPP in press Data U5MR from UNICEF and Lozano et al Lancet NMR from Oestergaard et al 2011 PLoS, Malawi DHS 1999, 2000, 2004, 2010 and MICS MDG 4 target from Countdown to 2015, decade report -- 2/3 reduction from 1990 U5MRwww.childmortality.org NMR reducing at 2% per year, double the regional average Only 5 national paediatricians! More in Health Policy Planning journal supplement Decade of Change for Newborn Survival and in IERG report panel and in Countdown June 2012 report

Changes in skilled birth attendance for Malawi, Source: Malawi DHS 1992, 2000, 2004, preliminary Malawi MICS 2006 Increased by 16% over the last 5 years Multiple approaches both supply and demand > 30% increase in numbers of nurse/midwives